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FunctionalAbilityEvaluationMedicalReport UtahDriverLicenseDivision P.O. Box144501 SLC,UT841144501 Phone:8019637325Fax:8019578698Email:dlmedical@utah.gov. LastNameFirstNameMiddleDateofBirthDriverLicenseNumberDriversSignatureDateThefollowingportionofthisformistobecompletedbyahealthcareprofessional.
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