Transcription of TPH/204
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TPH/204
12 of 12F - declaration - to be completed by medical Practitioner carrying out the examinationPlease ensure all sections of the form have been completed. Failure to do so will result in the form being the time of the physical examination and completion of this medical form, I had possession of the individual s full medical records. Yes No Where No , please state your reason(s) why:Examining doctor s detailsTo be completed by the doctor. Please print name and address in capital lettersPractice NameAddressPhoneI confirm that this report was completed by me at the physical examination and that I am currently GMC registered and licensed to practice in the s signature Surgery StampGMC Registration numberDateDDMMYYYYName (BLOCK CAPITALS)Applicant/Driver s name (BLOCK CAPITALS)TM004291 TPH/204 medical declaration Form Part 1 June 18 Restricted when , 04/06/20181 of 12 Transport for LondonLondon Taxi and Private HireTPH/204 medical DeclarationTM004291 TPH/204 medical declaration Form Part 1 June 18 MAYOR OF LONDONT ransport for London (TfL), the Licensing Authority, needs to be satisfied that all licensed Londontaxi and Private Hire vehicle drivers are medically fit.
Applicant/Driver’s name (BLOCK CAPITALS) TM004291 TPH/204 Medical Declaration Form Part 1 June 18 Restricted when completed Restricted when completed This page must be endorsed with applicant/driver's name, examining doctor's signature, surgery stamp and date TM004291 PT1 (Proof 5) Reverse Black Cyan Magenta Yellow
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