“ty 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 ,