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(Name and address of applicant:)ESR Personal ID:______ ___ ___ ___ To: EBR Office Paseo de Gracia, 86 9 Planta 08008 Barcelona ESPAA diploma@myebr.orgDate: ___Proof of Practice Years This is to certify that (Title:) ___ (First Name:) ___(Last Name:) ___ has been working as supervised staff radiologist in this hospital / institution from ___ to ___.Name and address of hospital / institution: ___ ___ ___ Street ___ Zip Code City Country Official stamp of hospital/institution:___ ___ Name
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