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PRIVACY AcT MA
TERIAL REMOV
ED
MEDICAL EVALUATION
This is to certify that I have determined that Eberline
Instrument Corporation employee,
—§
ss,
.
has no unusual medical conditions or physical
impairments
that would limit his normal duties of employment.
Base Line Blood Counts:
White Cell with Gifferential
Hemoglobin BeNorma)
vate 5A3(7%
ZX
Normal
// Abnormal
// Abnormal
a
Physician's Signature
Please type:
Signature Name
Street and No.
City
State
Zip
Telepnone
BRIVAGY ACT MATERIAL REMOVED ,