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Attachment F : <br />enltII <br />Aumiral Withdrawal Form <br />f .:l>rm ;~strtl<:ti ;)n~: <br />L DOH fm ~~en.:y P rer-;r~in~u ;;a 1\ ~S ~".'" I flI~1 is. c~ Ie to r.ce ~ re r;u eHI fo r :r1lffi·Jr;;a l <br />rrn:d k;t~n < f rom 1:=1 h~ .. lth Juri:c-cmo;. <br />2 . Too e.rd er:lnt i"ir.l:, r~ue.;,tl~ I.H ;i mf'~t. n!:ei!. to c:ll1p le1c t his ~nn , On;:. =mp l e t~ se;;n tIl e-t:-Il'1 <br />=n e:rmil itw ie u i:::a.!:>;a;!1e tt@do~. ~"'-11>" ;;a nd C:)~..5yQy '-dclJ e a;:19@-doh,w;;a,p , 11'\05 ~ol.ntTotlr.l ! <br />llfith d r ... .,.,.'· in t he .su.l:ject I j n~ <br />3. DOH Eme1Qc<1c!, Prc p ;;a re ~ :.s; _n'll F:lfOl1$C IfF I ..i ll ~"fd i l\'al c r !~ -=ts "lith th e W ;s iIT ;t=" "S1.:rt: <br />... acl;;ati::: l.--::'If)'$U FF,I,. c ;;am :tw.it)., Th en .;;n~ tIT: rc,ql:c:tt ~ b·e:n ;IfP'~'e b y <br />[}oH le cd e rl ]rill', O~ fill! sl2ft' ·1iIt ~~r ' to I=-:m th e: fe ~~e:stt1l ~i:;n.i:ms " e ithc:r t il '" 0; m , lit <br />JUFF t ~·ch .. Jn c r st=~k fr-'m th~ DOH cxfI",. <br />4 . If meilbti: :: ;I re .... ·-gThl hl e, 00 fPR rQff wllJ 0<)J1 tr.:t the re quu tln.; 1::01 h:2lt { 'lIi:ti:l11 tv <br />-nfirm sip pi ,; lxotbn :r1l~ F~j H,f~ txt. <br />5 . DOH EP ~..tll ~"sn "e~er artd erd~r ft lT1h~r U1t1~ n::q u estl~; ~1 he.2lt h JU riufiCtJ::> ,.n cute <br />t h e n u ,"be ( -~ P'~ NI-::>, ~n ~ Kant e-rn;.il 01-,111 ttl e: "P'F"" d ""tity ~f :i1ttiii!':ou: t-:-lin! ,~u.st ; 1; 1::-:..1 <br />hu.ltll ju ri:d ~=-n . o tirr>:ltd "im e -:ff arl{~1 d-e,F e Td .. "'flO" .. ur; n~.:.tth $ ~ti;)n . me re-:i>':d, <br />an -oC e.;(~~i:-l=i TI . <br />n, llIe re~lj e..sti'5 b::al he:llth Ju ud0;6.:~ mi l J~ :lnd daT.!!. t: ;ldcncw~d!Qc. r =e i ptcbnt'I,' r:l1s fo::n <br />de ll :"1. <br />7 . Th e r ~llllestin, l:dlu:21tli j ,il db. 'I i'll a;re: tc I m.r. .. <br />an ir,ati:-n bte .:; at l:aH t re : '~:lrl :HIt us ln.;th : AA tj ~-i r:ll Ret 11 f;xrn I p:a,;~ 31 . <br />-!l . DO EP /ill leu n Ille =rnp l :i:e~ Anti.-ir al "It ith -dr;r",;;al fvrm far 7 ;'t:m . <br />Req'~tin,s1oai1 ,Ilulth illl'Js.dlctlon,; <br />()'iPn:h .. ~iol\ r!ul the loaJihalth.j rintiction is requo:Jtina th·e mecf~ fO ~ <br />Co-nt~: T¢I~: <br />Ph o ne #: E-M ilil : <br />Reqlle.ted Ant"'i".h /incl ude ty pe .. ...., and qu antlty j : Shi ppi nS Add re.ss : <br />(&: Tami,fJu, 75.~" !Opadrs of Wp.illsJ <br />57