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- In the signature section, sign your name in INK as it appears on your application. This must be done in the presence of the examining physician.
- For the Tuberculosis Test section, enter the DATE OF TEST RESULT and circle the TYPE OF TEST (Skin Test or X-Ray). Fill in the RESULT field accordingly.
- Complete the Licensed Medical Provider's information by providing their signature, date, name, title, and business name and address.
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