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9410 20th Avenue Edmonton Alberta Canada T6N 0A4 Tel 780 437-9100 / Fax 780 437-7787 EYE EXAMINATION REPORT AB-95 2005-02 Personal Information please print Name Last First middle Address Apt. /Street Phone Number City Province Postal Code E-Mail Address Vision requirements Evidence of satisfactory vision as determined by a professional recognized person i*e* Oculist Optometrist Ophthalmologist Medical Doctor or Registered Nurse no more than one 1 year prior to the date of submission to ABSA. a Distant vision shall equal 20/30 or better in at least one eye either uncorrected or corrected* b Near vision acuity shall permit reading 0. 5 m continuous text N-4 at a 40 cm test distance with their habitual correction one or both eyes. The following are considered equivalent to the 0. 5 m performance Times Roman N-4 at 40 cm Reduced Snellen 40/50 Jaeger J2 at 40 cm 0. 5 m at 40 cm 0. 37 m at 30 cm To be completed by Eye Examiner I certify the person named above please check Meets Without correction Meets With correction Does not meet Check one of the following Oculist Optometrist Medical Doctor Registered Nurse Examiner s name please print Examiner s Signature Examiner s phone number Examination Date For ABSA use only File No Eye examination result satisfied Approved by Yes No Date. /Street Phone Number City Province Postal Code E-Mail Address Vision requirements Evidence of satisfactory vision as determined by a professional recognized person i*e* Oculist Optometrist Ophthalmologist Medical Doctor or Registered Nurse no more than one 1 year prior to the date of submission to ABSA. a Distant vision shall equal 20/30 or better in at least one eye either uncorrected or corrected* b Near vision acuity shall permit reading 0. a Distant vision shall equal 20/30 or better in at least one eye either uncorrected or corrected* b Near vision acuity shall permit reading 0. 5 m continuous text N-4 at a 40 cm test distance with their habitual correction one or both eyes. The following are considered equivalent to the 0. 5 m continuous text N-4 at a 40 cm test distance with their habitual correction one or both eyes. The following are considered equivalent to the 0. 5 m performance Times Roman N-4 at 40 cm Reduced Snellen 40/50 Jaeger J2 at 40 cm 0. 5 m at 40 cm 0. 5 m performance Times Roman N-4 at 40 cm Reduced Snellen 40/50 Jaeger J2 at 40 cm 0. 5 m at 40 cm 0. 37 m at 30 cm To be completed by Eye Examiner I certify the person named above please check Meets Without correction Meets With correction Does not meet Check one of the following Oculist Optometrist Medical Doctor Registered Nurse Examiner s name please print Examiner s Signature Examiner s phone number Examination Date For ABSA use only File No Eye examination result satisfied Approved by Yes No Date. /Street Phone Number City Province Postal Code E-Mail Address Vision requirements Evidence of satisfactory vision as determined by a professional recognized person i*e* Oculist Optometrist Ophthalmologist Medical Doctor or Registered Nurse no more than one 1 year prior to the date of submission to ABSA. a Distant vision shall equal 20/30 or better in at least one eye either uncorrected or corrected* b Near vision acuity shall permit reading 0. 5 m continuous text N-4 at a 40 cm test distance with their habitual correction one or both eyes. The following are considered equivalent to the 0.

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