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Get PA DL-126 2012-2024

MEDICAL ADVISORY BOARD 4/13/12 Provider: For more information relating to Medical Reporting, visit http://www.dmv.state.pa.us/centers/medicalReportingCenter.shtml. PATIENT INFORMATION (Please complete this form in its entirety) DRIVER’S LICENSE NO. HEIGHT FEET SEX LAST NAME(S) EYE COLOR INCHES JR. ETC DATE OF BIRTH MONTH DAY TELEPHONE NUMBER FIRST NAME E-MAIL (if applicable) YEAR STREET ADDRESS: P.O. Box number may be used in addition to the actual address.

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