Form I-693, Report of Medical Examination and Vaccination ...
2. 3. E. 1. Street Number and Name. Physical Address Other Information. Apt.Ste. Flr. Number. City or Town State. ZIP Code ... required tests and procedures to be completed. If it is determined that I willfully misrepresented a material fact or provided false or ... I have not had my license to practice medicine revoked, and I am not subject to ... ................
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