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Pittsburgh PostGazette Vision Care Service Record (This form to be maintained by the providers' office) SECTION I PROVIDER PATIENT SECTION Employee Name: Employee ID No.: Patient Name: Employee Plan

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The Pittsburgh Post-Gazette - Davis is a form that must be filed by certain individuals who have financial interests in or business relationships with the city of Pittsburgh.

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Information such as sources of income, investments, and business relationships with the city must be reported on the Pittsburgh Post-Gazette - Davis form.

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