Print this form and have a doctor fill it out
| THIS DOCUMENT MUST BE COMPLETED AND SIGNED BY A MEDICAL DOCTOR (M.D.) OR DOCTOR OF OSTEOPATHY (D.O.) LICENSED TO PRACTICE MEDICINE IN THE STATE OF FLORIDA OR THE APPLICANT’S STATE OF RESIDENCE. |
| I am familiar with the requirements of the Broward County Criminal Justice Testing Center’s “BASIC MOTOR SKILLS TEST”. | |
| I examined (patient’s name): _____________________________________________________________
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| on (date): _________________________________________, and found nothing to indicate that it would be medically inadvisable for him/her to attempt the aforementioned test.
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| __________________________________________________________________D.O. or M.D. Physician’s Signature |
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| __________________________________________________________________________________ (Print physician’s name) |
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| ____________________________________________ Physician’s License Number |
______________________________ Issuing State |
| ______________________________________________________________________________ Street Address |
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| ___________________________________________________________________________________ City State Zip Code |
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| ___________________________________________________________________________________ Telephone Number Fax Number |
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