Driver License Application (Page 2 of 2) in pdf

Do not have an established medical history or clinical diagnosis of epilepsy or any other condition which is likely to cause loss

of consciousness or any loss of ability to control a motor vehicle;

Do not have a mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with my ability to drive a

motor vehicle safely;

10.

Have distant visual acuity of at least 20/40 (Snellen) in each eye without corrective lenses or visual acuity separately corrected

to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both

eyes with or without corrective lenses, field of vision of at least 70º in the horizontal Meridian in each eye, and the ability

to recognize the colors of traffic signals and devices showing standard red, green, and amber;

11.

First perceive a forced whispered voice in the better ear at not less than 5 feet with or without the use of a hearing aid or,

if tested by use of an audiometric device, do not have an average hearing loss in the better ear greater than 40 decibels at 500

Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid when the audiometric device is calibrated to American National

Standard (formerly ASA Standard) Z24.5-1951;

12.

Do not use a Schedule I drug or other substance, an amphetamine, a narcotic, or any other habit forming drug; and

13.

Do not use any non-Schedule I drug or substance that is identified in the other Schedules in 21 part 1308 except when the use

is prescribed by a licensed medical practitioner, as defined in §382.107, who is familiar with the driver’s medical history and

has advised the driver that the substance will not adversely affect the driver’s ability to safely operate a commercial motor

vehicle;

14.

Do not have a current clinical diagnosis of alcoholism.

IF YOU CHECKED ALL THE BOXES ABOVE, SKIP SECTION B

SECTION B.

I FURTHER CERTIFY THAT I: (Check the appropriate box below)

YES NO

Have a federal variance for one of the medical conditions that I have selected below (select all that apply).

A federal variance must be submitted with a current medical examiner’s certificate when certifying to this section.

Diabetes

Vision

Limb

Seizures

Hearing

I CERTIFY THAT I HAVE READ, UNDERSTAND AND MEET THE PRECEDING QUALIFICATIONS, AND THAT I OPERATE OR

EXPECT TO OPERATE IN INTERSTATE COMMERCE, AND I AM BOTH SUBJECT TO AND MEET THE QUALIFICATION

REQUIREMENTS UNDER 49 C.F.R. PART 391. I MEET THE REQUIREMENTS OF CATEGORY 1, NON-EXCEPTED INTERSTATE.

I ALSO UNDERSTAND BASED UPON THIS CERTIFICATION THAT I AM REQUIRED TO OBTAIN AND PRESENT TO THE

DEPARTMENT A VALID MEDICAL EXAMINER’S CERTIFICATE UNDER 49 C.F.R. PART 391.45.

APPLICANT’S SIGNATURE

DATE

Sworn to and subscribed before me on this the

day of

Notary Public or Authorized Officer

FOR DEPARTMENT USE ONLY

This form may require one of the following restrictions to be placed on the commercial driver license.

P15 – Operation Class A exempt vehicle authorized

V – Medical variance documentation required

Class A – Texas Commercial Rules, General Knowledge, Combination, Air-brake (if applicable), Pre-trip, and any necessary

endorsement exams.

Class B – Texas Commercial Rules, General Knowledge, Air-brake (if applicable), Pre-trip, and any necessary endorsement exams.

Class C – General Knowledge and any necessary endorsement exams.

Skills exams required: Yes

A Medical Examiner’s Certificate is required.

Non-excepted Interstate

Driver License Application Page 2

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