Please print and take this form to your medical doctor (M.D) to be completed.
455 Spadina Ave., Suite 300 Toronto, Ontario M5S 2G8
Telephone: (416) 323-1818 or Toll free: (800) 263-1703 (USA & Canada only)
( ) Is the above in good health and free of communicable diseases?
( ) Results of T.B. Test
Is the above named person fit, healthy and able to work with the public?
( ) Yes ( ) No
If No, please explain why. Thank You.
Doctor’s Name (please print) Doctor’s Signature