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Telephones: 767-6600 - 6601 <602 - 6603 Cl e a r in g In d u s t r ia l Cl in ic 5548 WEST SIXTY-FIFTH STREET .... --............ cmcaao/iiLiHeu wow DIRECTORS ROSSRT e. SOYD. M.ORICHARD THORS, W.D. SENIOR CONSULTANT RHIUR FALK. M.D. CORPORATE MEDICAL DIRECTOR nATr Qefnhftr 18. 1983 AMERICAN GYAMAM1P r0'--------- 10-14-83 i 1 ,> .?- CYWI 3-001154 14565 Request for Physical Examination CYANAMZD American Cyanamid Company Central Medical Department PART A I TO: HUDH. _ Rnyrl Clearing Industrial Clinic Chicago, 11. 60638 DATE 1 ____________ in/11/Bi YOU ARE AUTHORIZED TO PERFORM A p r e-e mp l o y men t ______ p er io d ic PHYSICAL EXAMINATION ON Bovce J (Ls*t Name) (Fir*t) SOCIAL SECURITY NUMBER g] s pec ial tspeciw reason) High blood l.gad (Initial) PRESENT, OR APPLIED FOR, POSITION/TYPE OF WORK: General Factory AT (COMPANY LOCATION) 4500 West 15th Street DIVISION Polymer Products DEPARTMENT Polymer Chemicals CHARGE CODE 30-0299-0931 EXAMINATION REQUESTED BY (REQUESTER) SEND INVOICE TO (MAILING ADDRESS) REQUESTER'S TITLE 4500 West 15th Street Chicago, 11. 60623 TELEPHONE 3120522-2200 REQUESTER'S COMPANY LOCATION 4500 West 15th Street INSTRUCTIONS COMPANY REQUESTER 1. FULLY COMPLETE PARTA AND SEND ORIGINAL ANO PARTS 2 & 3 TO THE PHYSICIAN. 2. SEND PART4 TO: CORPORATE MEDICAL DIRECTOR AMERICAN CYANAMID COMPANY ONE CYANAMID PLAZA WAYNE, NJ 07470 3. SEND PARTS TO THE APPROPRIATE ACCOUNTS PAYABLE DEPARTMENT SHOWN IN PARTA. CONFIDENTIAL INFORMATION REDACTED PHYSICIAN 1. UPON COMPLETION OF EXAMINATION, COMPLETE PARTB AND SEND ORIGINAL FORM TO THE REQUESTER INDICATED IN PARTA. 2. SEND PART2 WITH YOUR INVOICE TO THE ACCOUNTS PAYABLE DEPARTMENT SHOWN INRARTA. 3. SEND PART 3, COMPLETED PHYSICAL EXAMINATION FORM. X-RAYS AND OTHER MEDICAL DATA AS IN THE PAST TO: CORPORATE MEDICAL DIRECTOR AMERICAN CYANAMID COMPANY ONE CYANAMID PLAZA WAYNE, NJ 07470 NA 255 Rav. 7/81'T."7/8t ORIGINAL 1 CYWI 3-001155 N14565.01 Telephones: 767-6600 - 6601 - 6602 - 6603 Cl e a r in g In d u s t r ia l Cl in ic 5546 WEST SIXTY-FIFTH STRSE^ --c h ic a u j , vx\m\?i*fa CORPORATE MEDICAL DIRECTOR AMERICA* CyiMlllin 03 ' E d ir ec t o r s ROBERT E. BOYD. M.O.`i RICHARD THOM, tl.O. SENIOR CONSULTANT PHILIP FALK. M.0. CYWI 3-00X156 N14565.02