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["情况  奖惩"]
["之前有无患过重大疾病或做过外科手术？如有，请说明。"]
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["                                                                   签名 :          "]
["                                                                    年    月    日"]
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["承担经济及法律责任。"]
["                                                                   签名 :          "]
["                                                                    年    月    日"]
["（说明：表格不够可附页）"]