Enclosure
3
QUICK~-RETURN FORM
NAME
SOCIAL SECURITY NUMBER
ADDRESS
ZIP
PHONE
(AREA CODE)
‘
i
(NUMBER)
I would like to have a medical examination.
{
TokReee
a
a.G SS
mado
laws
on
arrancetmatrts
We ee Ry ek we
(DATE)
fae
Ae oe
arn
asrvraminntion
Clas
Te et me ae
with the following
health care facility:
(Please fill
.
in name and
address of
Soin
facility)
I do not intend to request a medical examination
at this time.
REMARKS:
Enclosure 3
&
a“
I.
in
in
ae
‘
~~
,
.
i
.
2
_ - +
/
“...