Medical Certification Form - New Driver Applicant
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1Licensing – Driver Application
31-00 47
Avenue, 3
th
rd
Long Island City, NY
+1 718 391
Medical Certification Form – New Driver Applicant
ALL Medallion Driver and For-Hire Driver license applicants must have this form completed by a
Licensed Physician after a medical examination. No other form will be accepted.
When to get examined:
The date of your medical examination cannot be more than 90 days before the
date that you submit your TLC application.
How to submit this form:
You must submit this completed form to the TLC by attaching the form to the
online TLC application. If you have already submitted your online application,
you may email this form to: newdrivermr@tlc.nyc.gov, or mail it to:
New York City Taxi & Limousine Commission, Attention: New Applicant
Licensing Unit 31-00 47th Avenue, 3rd Floor Long Island City, NY 11101
When to submit this form: If you do not submit this form to the TLC within 90 days of submitting your TLC
application, your application will be denied.
If you have any questions, please call 718-391-5501 or visit TLC’s website at:
FOR LICENSED PHYSICIAN’S USE ONLY:
I certify that I have examined_____________________________________________,
(name of applicant)
the applicant for a NYC Taxi & Limousine Commission Driver’s License, on _________________.
(date of exam)
Based on this examination, 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.
Medically fit means that the applicant is of sound physical condition with good eyesight and no
epilepsy, vertigo, heart trouble or any other infirmity of body or mind to the extent that it would
render the applicant unfit for the safe operation of a licensed vehicle at all times of the day.
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 Number
THIS FORM MUST BE VALIDATED WITH AN OFFICIAL STAMP BY PHYSICIAN.
NEW DRIVER APPLICATION - Medical Form 5
.11.16
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