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Physician's Statement

Employee/Applicant
Name
To be completed by Physician
I have examined the individual named above and to the best of my knowledge he/she is good physical and mental health, free of any communicable diseases, and is able to function in his/her profession at full capacity. By signing below I certify that the above information is true.
Max. file size: 6 GB.
Title (Must Circle One):
MM slash DD slash YYYY
Address