rint or stamp) Address: D11600. &2000, obtain., enIkr edition, (SI is such that immunization(s) as indicated in Part C above is medic indicated. Numbyr: 5140400-0680-6) Physician Signature: Date: EFTA01709622 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 2.32.032, s. 1