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Get IA Certificate of Immunization 2006

Th: ______________ Parent/Guardian: _____________________________________ Address: ________________________________________________________ Phone: (___________________ ) I certify that the above named applicant has a record of age-appropriate immunizations that meet the requirement for licensed child care or school enrollment. Signature: ________________________________________ Date: _______________________ Physician, Physician Assistant, Nurse, Certified Medical Assistant A representativ.

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