Dot physical form fillable

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Medical Examination Report FOR COMMERCIAL DRIVER FITNESS DETERMINATION 649-F 6045 1. DRIVER S INFORMATION Driver completes this section Driver s Name Last First Middle Social Security No. Birthdate M/D/Y Address City State Zip Code Work Tel Age New Certification Sex M Recertification F Follow-up Driver License No. License Class State of Issue C D A B Home Tel 2. HEALTH HISTORY Date of Exam Other Yes No Any illness...
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