Get FL HSMV 72119 S 2018-2021
On examination and to submit this report to the Division of Motorist Services. ______________________________________ Patient’s Signature ______________________________________ Driver License Number ______________________________________ Patient’s Address, Street, and Number _____________________________________ City/State-Zip I AM A LICENSED PHYSICIAN AUTHORIZED TO PRACTICE UNDER CHAPTER 458, 459 OR 463, FLORIDA STATUTES, OR A LICENSED PHYSICIAN AT A FEDERALLY ESTABLISHED VETERANS’ HO.
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