Get And Sign Printable Utah State Functional Ability Evaluation Medical Report Form 2010

FUNCTIONAL ABILITY EVALUATION MEDICAL REPORT UTAH DRIVER LICENSE DIVISION TOP PORTION MUST BE COMPLETED BY APPLICANT - Please use BLACK ink Fax Number 801 957-8698 www. I also understand that I may revoke this authorization at any time by sending written notification to the Utah Driver License Division at the above address. I understand that if I fail to sign this authorization my driving privilege may be affected. I understand that this informat......