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Get BOP BP-A0630 2010-2024

BE RELEASED TO UNAUTHORIZED PERSONS Examining Facility Date of Examination Name of Patient: (Last Name, First Name, Middle Name) Social Security Number Purpose of Examination Statement of your present health and any medications currently used: Have you ever: (Please check each item) Yes No Do you (Please check each item) (1) Been treated for Tuberculosis? (7) Wear glasses or contact lenses? (2) Been treated for psychiatric condition? (8) Have vision in both eyes? (3) Been hospit.

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