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PRIVACY ACT MATERIAL REMOVED
MEDICAL EVALUATION
This is to certify that I have determined that Eberline
Instrument Corporation employee, |
.
has no unusual medical conditions or physical impairments
that would limit his normal duties of employment.
Base Line Blood Counts:
White Cell with Differential
Hemoglobin
Date C//¢(17
£/Normal
//Normal
// Abnormal
// Abnormal
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Physician's Signature
Please type:
VT.“et Mes rnp.
Signature Name
Street and fo.
All biGuirrerre , rer
City
State
— Lip
GIF -2TA -LFO/
Telephone
MATERIAL
PRIVACY ACT
D |
REMOVED
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