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Get UT DLD 134 2014

Mber: (801) 957-8698 _______________________________________________________________________________________________________________________________________ Last Name First Name Middle or Maiden Name Date of Birth Driver License or Driving Privilege Card Number By signing this form, I authorize my healthcare professional(s) to disclose specific health information regarding my physical, mental and emotional condition relevant to my ability to safely operate a motor vehicle, to the Utah Driver Lic.

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