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PHYSICIANS CERTIFICATE FOR MINOR WORK PERMIT Name of Student Applicant in full Date of Birth Distinguishing Characteristics if any Sex Male Female PHYSICIANS APPROVAL School District Building Parent

Physicians Signature Date Signed IS NOT IS Limited Certificate If Marked YES Employment should be Limited to Work Specified Below APPLICANT INFORMATION 333102 ORC 410902 ORC Height Weight Color of Hair ft in lbs Color of Eyes IN THEIR OPINION PHYSIC

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PHYSICIANS CERTIFICATE FOR MINOR WORK PERMIT Name of Student Applicant in full Date of Birth Distinguishing Characteristics if any Sex Male Female PHYSICIANS APPROVAL School District Building Parent






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