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Ction. DRIVER'S NAME (Last, First, Middle) SOCIAL SECURITY NUMBER BIRTHDATE SEX Recertification F ADDRESS (Number and Street) WORK TELEPHONE NUMBER (City or Town) HOME TELEPHONE NUMBER HEALTH HISTORY (Zip Code) LICENSE CLASS A 2. Follow-up (State) DRIVER LICENSE NUMBER B STATE OF ISSUE C D OTHER Driver completes this section, but medical examiner is encouraged to discuss with driver. YES NO YES NO YES NO Head/Brain injuries, disorders or illnesses Lung disease, emphys.

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