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Provide the appropriate data in the space ORIENTATION, No, disorientation Severe, disorientation, explain, below Explanation, JUDGMENT, Unimpaired, Mildly, Impaired, explain, below Severely, Impaired, explain, below Explanation, Yes, would, result, in, injury, hazard, or, accident Yes, CERTIFICATION, MEDICAL, SPECIALTY and ADDRESS.

Provide the considerable details the RETURN, THIS, FORM, TO TELEPHONE, and SOC box.

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