12. Urinary System
13. Male or Female Reproductive Systems
14. Pregnancy, Birth or Congenital Abnormalities
15. Muscular or Skeletal System
16. Miscellaneous
17. Other Injury, Illness, Treatment or Condition
18. Tobacco Use
19. Other Activities
ONLY complete this section if you need assistance with completing the medical information portion of this Application. Please note that this may require additional time to process your application.
Signature (or e-signature) of each listed child who has attained the age of 18
Complete this section if someone assisted you in the completion of this Application
Individual Uniform Application Form
OCI 26-503 (c. 06/2010)
