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Medical Information Bureau
P.O. Box 105, Essex Station
Boston, MA 02112
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I would like to request a copy of my Medical Information Bureau Report. You may send the release form to:
First Name:_______________________________
Middle Name: _________________________
Last Name:_____________________________
Generation:________
Current U.S. Street Address:_____________________________________
Apartment Number:______________
City:____________________________
State:___________________________
ZIP:_______________________
Signature_______________________________________
Thank you!
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