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<br /> PHYSICIAN, CHI ROPRACTOR~R - <br /> CHRISTIAN SCI ENCE PRACTITIONER CERTIFICATE <br /> STATE OF TEXAS ] <br /> COUNTY OF ] <br /> This is to certify that I have personal knowledge of the physical condition of <br /> ::Ind that he will <br /> be unable to appear at the polling place for the <br /> Election to be held on the <br /> day of , 19 <br /> 1. ( ) Because of pregnancy or possible del ivery she will be or may be <br /> unable to appear at the polling place for the above named election. <br /> 2, ( ) Because of sickness or physical disability _ he will be unable to appear <br /> at the polling place for the above named election. <br /> WITNESS MY HAND at County, Texas, th is the _ day of , 19 <br /> Signature of duly licensed physician or <br /> chiropractor or accredited Christian Science <br /> Practitioner. <br /> FORM 5-350 <br />