DOT Form

Medical Examiner's Certificate

(For Commercial Driver Medical Certification)

I certify that I have examined

Last Name:

First Name:

in accordance with

(please check only one):

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 (Check all that apply) or The Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) with any applicable State variances (which will only be valid for intranste operations), and with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when (check all that apply)

Checkbox list

Wearing corrective lenses

Wearing hearing aid

Accompanied by a (Please input below) waiver/exemption

Accompanied by a Skill Performance Evaluation (SPE) Certificate

Driving within an exempt intracity zone (49 CFR 391.62) (Federal)

Qualified by operation of 49 CFR 391.64 (Federal)

Grandfathered from State requirements (State)

This information I have provided regarding this physical examination is true and complete. A complete Medical Examination Report Form, MCSA-5875, with any attachments embodies my findings completely and correctly, and is on file in my office.

Medical Examiner's Certificate Expiration Date

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Medical Examiner's Signature

Medical Examiner's Telephone Number

Date Certificate Signed

Medical Examiner's Name (please print or type)

Radio buttons

MD DO Physician Assistant Chiropractor Advanced Practice Nurse Other Practitioner(specify)

If Other, Please specify

Medical Examiner's State License, Certificate, or Registration Number

Issuing State

Natinal Registry Number

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Driver's Signature

Driver's License Number

Issuing State/Province

Driver's Address

Street Address

City

State/Province

Zip Code:

Your information will be encrypted.