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Get INSTRUCTIONS TO MEDICAL EXAMINER

Ns and Recertification complete ALL items on pages 1 through 4 of the form and sign where indicated on page 4. For Follow-up Examinations complete ONLY those items which require follow-up information and/or evaluation from a prior examination. Sign the form where indicated on page 4. DRIVER INFORMATION (to be completed by the driver and reviewed by the medical examiner) Driver s Last Name First M.I. Date of Birth (Month/Day/Year) Age Sex Male Street Address City Client/License ID.

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