This government document is issued by Podiatric Medical Examiners Board (0140) for use in Oklahoma
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https://www.google.com/url?client=internal-element-cse&cx=011016168438751653346:hresk_9zb-o&q=https://www.okmedicalboard.org/occupational_therapists/download/84/OT%2BFORM%2B5%2BW-INSTRUCTIONS%2B10-23.pdf&sa=U&ved=2ahUKEwidvtjEsceUAxXrTqQEHQhgExE4ChAWegQIChAB&usg=AOvVaw3ubgfHg0pH0A3QVMByNPWf