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[[preprinted form]]
MEDICAL RECOMMENDATION FOR FLYING DUTY
(Detach Diagnosis for other than medical use of form)

DATE ^[[1 Aug 67]]

TO: ^[[Commander 13th AF]]

FROM: ^[[USAF Hospital Clark AB, Philippines

HOSP CODE ^[[P151]]

CERTIFICATE

[[checked checkbox]] (FOR INCOMING FLYING PERSONNEL ONLY)
I CERTIFY THAT I AM ON FLYING STATUS ACCORDING TO CURRENT ORDERS AND THAT I HAVE HAD NO ILLNESS OR INJURY SINCE LEAVING MY LAST STATION, EXCEPT AS RECORDED BELOW.

[[checked checkbox]] I CERTIFY THAT I HAVE BEEN NOTIFIED OF THE RECOMMENDATIONS BELOW AND UNDERSTAND THE ACTION BEING TAKEN THIS DATE.

[[unchecked box]]I HAVE BEEN OFFICIALLY NOTIFIED THIS DATE THAT I (have been grounded because of physical disqualification for flying duty) (am physically qualified for flying duty).

SIGNATURE OF FLYER ^[[B O Davis Jr]]

CLEARANCE FOR FLYING DUTY IS GIVEN UNDER THE FOLLOWING CIRCUMSTANCES

[[checked checkbox]] 1. REPORTING TO A NEW STATION ^[[1 Aug 67]]

2. ANNUAL MEDICAL EXAMINATION

[[checked checkbox]] 3. OTHER REQUIREMENT FOR CLEARANCE (Specify) ^[[Flying Class II w/waiver]]

13. AERO ORDERS
[[3 column format]]
   | INDIVIDUAL PRESENTLY SUSPENDED BY|   |
AERO |   |   |
HEADQUARTERS |   |   |
PARAGRAPH NO.|   |   |
DATE |   |   |

13. COMPETENT CERTIFYING AUTHORITY (When box (4), (5) or (6) in item 14 is checked, indicate authority to certify as physically qualified.)

   | BASE |   | NO. AIR FORCE |   | MAJOR AIR COMMAND |   | HQ USAF |


1. LAST NAME - FIRST NAME - MIDDLE INITIAL ^[[
DAVIS, BENJAMIN O. Jr.]]

2. GRADE ^[[Lt Gen]]

CODE ^[[7]]

SERVICE NUMBER ^[[FR 1206]]

4. AGE ^[[54]]

5. TOTAL FLYING TIME ^[[4000]]

6. ORGANIZATION AND MAJOR COMMAND OF ASSIGNMENT ^[[13th AF, APO SF 96274 (PACAF)]]

CODE ^[[RA]]

7. MONTH IN WHICH FLIGHT REQUIREMENTS WERE LAST MET ^[[-]]


8. RATING, DESIGNATION OR FLYING DUTY ^[[Cmd Pilot]]

CODE ^[[A]]


9. ACTUAL DATE FOUND MEDICALLY INCAPACITATED TO FLY (Day, Month, Year) ^[[-]]

CODE ^[[-]]

10. ESTIMATED DURATION OF INCAPACITY TO FLY ^[[-]]

11. STANDARD FORM 88 15 ATTACHED ^[[-]]
YES ^[[-]] | NO ^[[-]]|

12. SERIOUS ILLNESS (If answer is "yes", attach Standard Form 88) 
YES ^[[-]] | NO ^[[-]] |

14. TYPE OF ACTION RECOMMENDED (Check one)| MONTH AND YEAR |

   |(1) EXCUSAL NOT TO EXTEND BEYOND LAST DAY OF |   |
   |(2) GROUNDING NOT TO EXTEND BEYOND LAST DAY OF |   |
   |(3) SUSPENSION AS OF FIRST DAY OF |   |
   |(4) REMOVAL OF EXCUSAL |   |
   |(5) REMOVAL OF GROUNDING |   |
   |(6) REMOVAL OF SUSPENSION |   |
16. TOTAL DAYS (Number of days from actual date of incapacitation (item 9)to date of certification by competent authority as physically qualified to fly).

DAYS DURATION IN MEDICAL FACILITY

REMARKS
^[[This clearance expires: 18 Dec 67
Glasses will be worn while performing those air crew duties requiring the corrected visual acuity.]]

TYPED OR PRINTED NAME AND GRADE OF FLIGHT SURGEON OR AVIATION MEDICAL
^[[JOHN T MAHONEY CAPT USAF MC FMO]]

SIGNATURE ^[[J Mahoney]]