Skill Performance Evaluation Certificate Application Form Page 25
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25MEDICAL EXAMINER’S CERTIFICATE
I certify that I have examined
In accordance with the Federal Motor Car-
rier 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:
wearing corrective lenses
driving within an exempt intracity zone (49 CFR 391.62)
wearing hearing aid
accompanied by a Skill Performance Evaluation Certificate (SPE)
accompanied 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)
Chiropractor
MD
DO
Advanced
Practice
Physician
Nurse
Assistant
MEDICAL EXAMINER’S LICENSE OR CERTIFICATE NO./ISSUING STATE
DRIVER’S LICENSE NO.
STATE
SIGNATURE OF DRIVER
ADDRESS OF DRIVER
MEDICAL CERTIFICATE EXPIRATION DATE
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