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H problems? YES NO If YES, please give the condition and the name and address of the doctor treating you. 11. Please give the date you were last seen by: Your GP Your Consultant Driver declaration: I declare that I have checked the details given in Questions 1 10 and that to the best of my knowledge and belief, they are correct. Please be aware that incomplete answers may result in delays. Signed: Date: NAME: DOB: DRIVER NUMBER: REF: Page 3 of 5 Rev Jul 13 CONSENT Consent to t.

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