PRIVACY ACT MATERIAL REMOVED
MEDICAL EVALUATION
This is to certify that I have determined that Eberline
Instrument Corporation employee,
|
.
has no unusual medica} conditions or physical impairments
that would limit his normal duties of employment.
Base Line Blood Counts:
White Cell with Differential
(4 7.
Hemoglobin /¥ Normal
Date
ie 7}
// Normal // Abnormal
_
// Abnormal
tll
Jied-—
ha
hysician's Signatyre
Please type:
:
+
Signature Name
T31
Tacrers
Street and No.
_
:
ity
.
.
ces
State
Oe FAD TIYO
Ctrele,
Suite
% 1 1%
“ip
Telephone
pRIVACY ACT MAT ERIAL REMOVED
105