Medical Card Form Page 2
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1
2Please read the following questions and answer YES or NO accordingly:
Interstate non-excepted: You are an Interstate non-excepted driver
and must meet the Federal DOT medical card requirements
(e.g. – you are “not excepted”).
YES
NO
Interstate excepted: You are an Interstate excepted driver and do
not have to meet the Federal DOT medical card requirements.
YES
NO
Intrastate non-excepted: You are an Intrastate non-excepted driver
are required to meet the medical requirements for your State.
YES
No
Intrastate excepted: You are an Intrastate excepted driver and do
not have to meet the medical requirements for you State.
YES
NO
Signature: ________________________________________
Date: ____________
Please attach a photocopy of your driver license and current medical card
in space provided below.
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