Document peeG7EqYybqKEJj60KYJzMYw

Telephones: 767-6600 - 6601 - 6602 - 6603 Cl e a r in g In d u s t r ia l Cl in ic 5548 WEST SIXTY-FIFTH STREET CHICACO, ILLINOIS 60638 DIRECTORS ROBERT E. BOYD.' M. D RICHARD THORS. M D. SENIOR CONSULTANT PHILIP FALK. H O .zDl^ DI:-5^T03_______________ d a t e _____ Juwa 3Qf laiA CO.________________________ TO55V --------------------------------------------------- CYWI 3-001217 * Request for Physical Examination ^ CYANJUVHD American Cyanamid Company Central Medical Department rf. r" d r . -------- j DATE YOU ARE AUTHORIZED fl PRE-EMPLOYMENT A PERIODIC PHYSICAL EXAMINATION ON ... . (!Auv/<v (Last Name) (Firat) SOCIAL SECURITY NUMBER rm-m-rrm .) SPECIAL (Specify reason) (Initial) - PRESENT. OR APPLIEO FOR. POSITION/TYPE OF WORK: QcyveHAt- ffrbTo&i' QtV ISIQN r BEPARTMENT roL<s/n<Z EXAMINATION REQUESTEO BY (REQUESTER) U.P GfifFfJsH REQUESTER'S TITLE ViA<6T WfrtibGe7Z ' TELEPHONE AT (COMPANY LOCATION) .__ 4-&0 o /s ' * S i. a, (shiM/CAL, CHARGE COPE . 36 ' d 9 <? -/ 7 ? SEND INVOICE TO (MAILING AOORESS) ui iS'*L^'CX3 * f - REQUESTER'S COMPANY LOCATION 4^(rd UJ. fX ' * S/ WAYNE, NJ 07470 3. SENO PARTS TO THE APPROPRIATE ACCOUNTS PAYABLE DEPARTMENT SHOWN IN PARTA. PHYSICIAN 1. UPON COMPLETION OF EXAMINATION, COMPLETE PARTS AND SENO ORIGINAL FORM TO THE REQUESTER INDICATED IN PARTA. 2. SEND PART 2 WITH YOUR INVOICE TO THE ACCOUNTS PAYABLE DEPARTMENT SHOWN IN PARTA. 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 7/av^-7/8i ORIGINAL I CYWI 3-001218 N14762.01 c Summary of C Physical Examination NAMt Calvin Davis AOORCSS 637 Lawndale NATURE o f WORK/* /) ______ e x a min a t io n r e o u c s t e d 9y r\ ri SIGNIFICANT HISTORY AZtL CYANAMtD American Cyanamtd Company /> // (CHECK ON E) Sr PRE-PLACEMENT PERIODIC SPECIAL -6/17 84 AGE . 39 _ * // UCPICULTyAAL. UCDEPCC. CTC.f SIGN1FICANT PHYSICAL FINOINGS CONFIDENTIAL INFORMATION REDACTED N * 2Tt t-TT * S-77 CORPORATE MEOICAL DIRECTOR AMERICAN CYANAMIO COMPANY WAYNE, N. J. 07470 CYWI 3-00X219 N14762.02