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Mber Birth Date (mm-dd-yyyy) REQUIRED FOR U.S. IMMIGRANT VISA APPLICANTS NOT REQUIRED FOR REFUGEE APPLICANTS Alien (Case) Number NOTE FOR PANEL PHYSICIANS: For refugee applicants, please complete only if reliable vaccination documents are available. 1. Immunization Record Vaccine History Transferred From a Written Record (List Chronologically from Left to Right) Vaccine Given by Date Date Date Date Panel Received Received Received Received Physician (mm-dd-yyyy) (mm-dd-yyyy) (mm-dd-yyyy) (.

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