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Get Certificate Of Medical Exmination Form

-R0073 Part A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE 1. NAME (last, first, middle) 2. SOCIAL SECURITY ACCOUNT NO. 3. SEX 4. DATE OF BIRTH MALE FEMALE 5. DO YOU HAVE ANY MEDICAL DISORDER OR PHYSICAL IMPAIRMENT WHICH WOULD INTERFERE IN ANY WAY WITH THE FULL PERFORMANCE OF THE DUTIES SHOWN BELOW? YES 6. I CERTIFY THAT ALL THE INFORMATION GIVEN BY ME IN CONNECTION WITH THIS EXAMINATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. NO (signature of applicant) (If your answer is "YES".

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