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Get NY LIC62 2017

Tate Zip License Number (if, licensed) License Type: 2 Physician TO BE FILLED IN BY EXAMINING PHYSICIAN (Please print) Name of Physician Address of Physician City State Physician’s Signature Zip Date __________________________________________ _________________________________________ 3 General Health Assessment   Fitness is being physically and mentally capable of undertaking the tasks that an individual is required to carry out and is licensed to engage in by the NYC Depar.

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