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14 Form 3040 which easy be used) Mock Plumbot. 5744400.3040-2) Authorized Signature-- Date EFTA01709711 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.032, 402.305, 402.313, Florida Statutes; rules 64D-3.011, 65C-22.006, 65C-20.011, Florida Administrative Code LAST NAME PARENT OR GU

services of the United States. 0 0 If E. Is YES, is the parent on active duty? Check service below: 0 Air Force 0 Army 0 Coast Guard 0 Marines 0 National Guard 0 Navy indicate wilh an he longest. Prekindergarten Prekindergarten Parent Program Applicable (17) PRESCHOOL ENROLLMENT IsFORIAATION Place an X by e

(46f DATA ENTRY COMPLETED BY DATE S/ DATE PBSD 0636 (REV. 4/6/20015.29/2001) page 2 of 2 EFTA01710389 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032, s. 10D-3.088, F.A.C. and s. 10M-12, F.A.C. LAST NAME PARENT OR GUARDIAN Directions: • Enter all appropriate doses and

ed services of the United States. 0 0 If E. Is YES, Is the parent on active duty? Check service below: 0 Air Force 0 Army • Coast Guard 0 Marines 0 National Guard 0 Navy (10 PRESCHOOL ENROLLMENT INFORMATION Place an X by each program attended. Also, indicate with an asterisk r ) the program your child was In the lon

FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.03Z, 402.305, 402.313, Florida Statutes; rules 640-3.011, 65C-22.006, 65C-20.011, Florida Administrative Code LAST N FIRST NAME MI

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I PHYSICIAN OR CONIC NAME (PLEASE PRINT) JATELY IMMUNIZED AGAINST 'DANCE. -//,1/2,73 DATE EFTA01710101 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032, a 10D-3.088, F.A.C. and S. 10M-12, F.A.C. ATE PARENT OR GUARDIAN FIRS I MI DOB moinAnta Child's 5Stt (optional) ST

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