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Get Dl691 2007-2024

ENT BE LIkELY TO AFFECT HIS/HER DRIVING ABILITY? No DATE Yes (If Yes, please explain) PRACTITIONER’S SIGNATURE X PRACTITIONER’S PRINTED NAME PRACTITIONER’S ADDRESS TELEPHONE NUMBER ( CITY Part D APPLICANT’S CERTIFICATION STATE DATE SIGNATURE X Refer to DS Office LINE DATE/SEqUENCE APPROVED DENIED DL 691 (REV. 12/2007) WWW ) zIP CODE I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. AUTHOR.

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