Medical Certification Form - New Application printable pdf download

Medical Certification Form - New Application

MEDICAL CERTIFICATION FORM - NEW APPLICATION

_______________________________________________________________________________________________________

Please visit our website for more information at:

or our office at 31-00 47

Avenue,

Floor, Long Island City, NY 11101 or contact our Call Center at 718-391-5501.

Medallion and For-Hire Operator license applicants

are required to have this form completed by a Licensed Physician

Medical Exam Requirement

This form must be completed, signed and stamped by a licensed physician. No other form can be used or will

be accepted.

The date of the examination cannot be more than ninety (90) days prior to the date you submit your application.

_______________________________________________________________________________________________________

This is to certify that I have examined

(name of applicant)

the applicant for a NYC Taxi and Limousine Commission TLC Driver’s License,

, and based on my examination reported herein,

(date of exam)

it is my opinion that s/he:

is medically fit to safely operate a TLC licensed vehicle.

is not medically fit to safely operate a TLC licensed vehicle.

Medically fit means that the applicant is of sound physical condition with good eyesight and no

epilepsy, vertigo, heart trouble or any other infirmity of body or mind to the extent that it would

render the applicant unfit for the safe operation of a licensed vehicle at all times of the day.

Physician’s Last Name, First Name

Physician’s Signature

Physician’s License #

Number & Street (Mailing Address)

City

State

Zip Code

State in which Physician is licensed

Phone# (

) ________-_______________

Official Stamp Required

THIS FORM MUST BE VALIDATED WITH AN OFFICIAL STAMP BY PHYSICIAN.

NEW DRIVER APPLICATION - Medical Form 2.09.16

Medical Certification Form - New Application