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MEDICAL EXAMINER'S CERTIFICATE

I certify that I have examined in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified; and, if applicable, only when:

This is a checkbox wearing corrective lenses

This is a checkbox wearing hearing aid

This is a checkbox accompanied by a ________ waiver/exemption

This is a checkbox driving within an exempt intracity zone (49 CFR 391.62)

This is a checkbox accompanied by a Skill Performance Evaluation Certificate (SPE)

This is a checkbox qualified by operation of 49 CFR 391.64


The information I have provided regarding this physical examination is true and complete. A complete examination form with any
attachment embodies my findings completely and correctly, and is on file in my office.

SIGNATURE OF MEDICAL EXAMINER TELEPHONE DATE
MEDICAL EXAMINER’S NAME (PRINT) This is a checkbox MD  This is a checkbox DO   This is a checkbox Chiropractor
This is a checkbox Physician Assistant
This is a checkbox Advanced Practice Nurse
MEDICAL EXAMINER’S LICENSE OR CERTIFICATE NO. / ISSUING STATE
SIGNATURE OF DRIVER DRIVER’S LICENSE NO. STATE
ADDRESS OF DRIVER
MEDICAL CERTIFICATE EXPIRATION DATE