Medical Certification Form printable pdf download

MEDICAL CERTIFICATION FORM

For-Hire Operator Renewing Applicants

_______________________________________________________________________________________________________

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.

(THIS IS REQUIRED TO MAINTAIN YOUR LICENSE)

Per Section 19-505(d) of the Administrative Code of the City of New York all For-Hire Operator License applicants were required to submit a medical

form which indicates that they are fit to safely operate a TLC licensed vehicle. As this form was not initially collected when your application for licensure

was accepted and processed you must now submit this form with your upcoming renewal in order to renew your license. This is a one-time submission.

You must submit this form in addition to all other requirements of licensure in order to renew your license. Failure to submit this form by the time your

license expires will result in the non-renewal of your license. The form must be an original form signed and dated by a licensed Doctor.

Medical Exam Requirements

You must submit this original form with your renewal.

Failure to submit this form by your expiration date will result in the denial of your license renewal.

This form must be completed, signed and stamped by a licensed doctor. 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 renewal.

This is to certify that I have examined

(name of applicant)

the applicant for a NYC Taxi and Limousine Commission TLC Driver’s License Renewal bearing license

number,

, and based on my examination reported herein,

(date of exam)