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Ddress City, State, Zip I hereby certify that the applicant below has an average loss in the speech frequencies (500 to 2,000 Hertz) in the better ear is 86 decibels, I.S. O. or worse. Physician’s Signature Date TO BE COMPLETED BY APPLICANT Vehicles qualified to display special decal or placard as follows: Passenger Vehicles, 1 ton trucks and vans as rated by the manufacturer which are used only for personal transportation, light trucks and vans ½ and ¾ ton as rated by the manufacturer. .

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