Fillable Printable Medical Examner's Certificate

Medical Examner's Certificate

MEDICAL EXAMINER’S CERTIFICATE

I certify that I have examined _____________________________________________________________ in ac cordan ce wit h the Federal Motor Carrier Safety

Regulat ions (49 CFR 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified, and, if applicable, onl y whe n:



wearing corrective lenses



driving within an exempt intracity zone (49 CF R 391.62)



wearing hearing aid



accom panied by a Skill Performance Evalu ation C erti ficate (SPE)



ac com pani ed by a______________________ waiver/exemption



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)

 MD  Chiropractor



Advanced Practice Nurse



Physician Assistant



Other Practitioner

MEDICAL EXAMINER’S LICENSE OR

CERTIFICATE NO./ISSUING STATE

NATIONAL REGISTRY NO.

SIGNATURE OF DRIVER

INTRASTATE ONLY



YES

 NO

CDL



YES

 NO

DRIVER’S LICENSE NO.

STATE

ADDRESS OF DRIVER

MEDICAL CERTIFICATION EXPIRATION DATE