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