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Get CA DLSE-277 2012-2024

_________ In my opinion, (please circle) he / she is / is not than one month, infant is / is not at least 15 days old, . Signature physically fit to be employed in the production of motion pictures and television. If less was / was not carried to full term, and is / is not physically able to perform. ____________________________________________________ M.D. Date ________________________ Remarks *PLEASE USE DOCTOR’S OFFICE STAMP ON APPLICATION TO ENSURE AUTHENTICITY.* DLSE- 277 (Rev. 03/1.

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