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Fillable DD Form 771, Eyewear Prescription, July 1996 - DTIC - dtic

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(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974 - Use DD Form 2005.) EYEWEAR PRESCRIPTION TO: (Lab) DATE ACCOUNT NUMBER ORDER NUMBER FROM: NAME (Last, First) SSN GRADE ADDRESS/UNIT PHONE ADDRESS CONTINUED SHIP TO: CLINIC PATIENT CITY, STATE, ZIP AD RES NG RET OTHER* A N AF MC CG PHS OTHER* FRAME EYE BRIDGE TEMPLE COLOR PD DIST NEAR LENS TINT MATERIAL PAIR CASE SPHERE...
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