Form 4.01.10 - Medical Certification Form - City Of New York Taxi & Limousine Comission

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Licensing and Standards Division
32-02 Queens Boulevard, 2nd Floor,
Long Island City, New York 11101-2324
1893 Richmond Terrace, Staten Island, NY 10302
Tel: 212.227.6324,
Note: “Yellow” Taxicab applicants only are required to complete Medical Form history
MEDICAL CERTIFICATION FORM
This is to certify that I have examined
(name of applicant)
The applicant for a NYC Taxi and Limousine Commission TLC Driver’s License,
on
, and based on my examination reported herein,
(date of exam)
It is my opinion that s/he:
Is medically fit to safely operate a TLC licensed vehicle.
Is not medically fit to safely operate a TLC licensed vehicle.
If not, list disqualifying reasons:
Physician’s Last Name, First Name
Physician’s Signature
Number & Street (Mailing Address)
Physician’s License #
City
State
Zip Code
State in which Physician is licensed
Phone# (
) ________-_______________
Official Stamp Required
THIS FORM MUST BE VALIDATED WITH AN OFFICIAL STAMP BY PHYSICIAN.
Medical Form 4.01.10

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