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	100 Disability Services, Irvine, CA, 3083 fax Verification of Medical/Physical/Perceptual Impairment Student Name (Please PRINT clearly) _______________________________________ Birthdate _ Add to Reading List Document Date: 2016-02-16 16:41:10 Open Document File Size: 109,30 KB Share Result on Facebook

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100 Disability Services, Irvine, CA, 3083 fax Verification of Medical/Physical/Perceptual Impairment Student Name (Please PRINT clearly) _______________________________________ Birthdate _Add to Reading List