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Form 649-F - Medical Examination Report - Federal Motor Carrier Safety Administration Page 9

MEDICAL EXAMINER’S CERTIFICATE

I certify that I have examined _____________________________________________________________ in accordance with the Federal Motor Carrier Safety

Regulations (49 CFR 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when:

 wearing corrective lenses

 driving within an exempt intracity zone (49 CFR 391.62)

 wearing hearing aid

 accompanied by a Skill Performance Evaluation Certificate (SPE)

 accompanied by a______________________ waiver/exemption

 qualified by operation of 49 CFR 391.64

The information I have provided regarding this physical examination is true and complete. A complete examination form with any attachment embodies my

findings completely and correctly, and is on file in my office.

SIGNATURE OF MEDICAL EXAMINER

TELEPHONE

DATE

 MD

 Chiropractor

MEDICAL EXAMINER’S NAME (PRINT)

 DO

 Advanced Practice Nurse

 Physician Assistant

 Other Practitioner

MEDICAL EXAMINER’S LICENSE OR

NATIONAL REGISTRY NO.

CERTIFICATE NO./ISSUING STATE

SIGNATURE OF DRIVER

INTRASTATE ONLY

CDL

DRIVER’S LICENSE NO.

STATE

 YES

 NO

ADDRESS OF DRIVER

MEDICAL CERTIFICATION EXPIRATION DATE

Form 649-F - Medical Examination Report - Federal Motor Carrier Safety Administration Page 9