Application For Intrastate Medical Waivers - Mass Rmv (Page 3 of 4) in pdf

Application For Intrastate Medical Waivers - Mass Rmv Page 3

Other Comments:

(3) Diabetic Conditions: Has the applicant ever had a hypoglycemic episode or spell?

YES

The applicant is not at risk or is no longer a risk of suffering hypoglycemic episodes or spells for the following specific reasons:

Recommended date for the Registry to re-evaluate the applicant’s ability to operate a commercial motor vehicle safely intrastate only:

(Specify month/year)

(4) Loss or Impairment of limb: Specify limb(s) affected and nature of impairment:

(5) Hearing Impairment: Specify degree of impairment and include any pertinent comments:

Please check one of the following categories:

I hereby certify that in my professional opinion and to a reasonable degree of medical certainty,

the applicant named above is medically qualified to operate a commercial motor vehicle safely.

the applicant named above is NOT medically qualified to operate a commercial motor vehicle safely.

Physician’s Name (print)

Telephone

Registration # ___________

Street Address

City___________________________________________

Signature

Date__________________________________________

Application For Intrastate Medical Waivers - Mass Rmv Page 3