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Letters while completing this form Name/ Initials/ Title : Tel No. Departure City: Tel No. Arrival City: Proposed Itinerary airline(s), flight number(s), class(es), date(s), Segment(s) reservation status Transfer from one flight to another often requires Longer connecting time C Nature of disability Medical Clearance Required D Is stretcher needed on board (all stretcher cases must be escorted) E Intended Escort (Name, Sex, age, professional qualification, segments if different fro.

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