Application For Intrastate Medical Waivers - Mass Rmv Page 2
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4APPLICATION FOR INTRASTATE MEDICAL WAIVERS
TO OPERATE CLASS A, B, OR C COMMERCIAL MOTOR VEHICLES
APPLICANT INFORMATION:
Name:
D.O.B. :
/
/
.
License #:
Class:
Endorsements:
Expiration:
/
/
Residential Address:
Telephone
Employer/Company Name:
Company Address:
I hold a valid Massachusetts Operator’s License, Class
, am engaged only in intrastate commerce within the borders of
Massachusetts, and hereby apply to the Registry of Motor Vehicles for a waiver to operate Commercial Motor Vehicles of this
class.
Applicant’ signature:
Date:
/
/______
FALSE STATEMENTS ARE PUNISHABLE BY FINE, IMPRISONMENT, OR BOTH.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION:
I hereby authorize the physician completing this form to discuss and release any or all medical records pertaining to its content with or to
representatives of the Registry of Motor Vehicles.
Applicant’s signature:
Date:
/
/_____
THIS PART OF THE APPLICATION MUST BE FULLY COMPLETED BY A PHYSICIAN: A MEDICAL
DOCTOR WHO IS LICENSED TO PRACTICE IN THE COMMONWEALTH OF MASSACHUSETTS.
To the Physician: Please complete the relevant section (1) through (5) below and complete the remainder of the application in full .
(1) Vision Impairments: Combined Horizontal Peripheral Field of Vision (record in degrees):
Distant Visual Acuity (Snellen): Left Eye (OS) 20/
Right Eye (OD) 20/_______
(If the applicant uses corrective lenses for driving please specify visual acuity above as corrected with RX).
Does the applicant use corrective lenses for driving?
YES
NO
Is the applicant able to distinguish the colors red, green, and amber?
YES
NO
(2) Cardiovascular Conditions:
Does the applicant have an implanted cardiac defibrillator?
YES
NO
Was the defibrillator implanted for a ‘sudden death” event?
YES
NO
OR
Was the defibrillator implanted as a preventative measure?
YES
NO
Does the applicant have AHA functional Class III or Class IV heart disease (see attached guidelines)? YES
NO
Specify AHA functional Class and symptoms: (see attached guidelines)
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