Examiner Certificate Form PDF Details

Are you thinking of becoming an examiner? If so, you will need to submit an Examiner Certificate Form to the National Highway Traffic Safety Administration (NHTSA). This form is used to verify your qualifications and experience as an examiner. In order to complete the form, you will need to provide information about your education and experience as an examiner. The NHTSA will use this information to determine if you are qualified to be an examiner. The Examiner Certificate Form is a PDF document that can be downloaded from the NHTSA website. The form must be completed and submitted by mail or fax. You can also submit the form online. The deadline for submitting the Examiner Certificate Form is August 1st for examiners who wish to become certified in September of that year or later. Examiners who wish to become certified in August of that year or earlier must submit the form by March 1st. If you have any questions about the Examiner Certificate Form, please contact the NHTSA at 20

QuestionAnswer
Form NameExaminer Certificate Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmedical examiner's certificate form, certificate medical examiner, medical examiner's certificate dmv, dot examination certification

Form Preview Example

Form MCSA-5876

OMB No. 2126-0006 Expiration Date: 11/30/2021

Public Burden Statement

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 1 minute per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

U.S. Department of Transportation

MEDICAL EXAMINER'S CERTIFICATE

Federal Motor Carrier

(FOR COMMERCIAL DRIVER MEDICAL CERTIFICATION)

Safety Administration

I certify that I have examined Last Name:

 

First Name:

 

in accordance with (please check only one):

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 (check all that apply) OR

the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) with any applicable State variances (which will only be valid for intrastate operations), and, with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when (check all that apply):

Wearing corrective lenses

Wearing hearing aid

Accompanied by a

 

waiver/exemption

Accompanied by a Skill Performance Evaluation (SPE) Certificate

Driving within an exempt intracity zone (49 CFR 391.62) (Federal)

Qualified by operation of 49 CFR 391.64 (Federal)

Grandfathered from State requirements (State)

Medical Examiner's Certificate Expiration Date

The information I have provided regarding this physical examination is true and complete. A complete Medical Examination Report Form,

MCSA-5875, with any attachments embodies my findings completely and correctly, and is on file in my office.

 

Medical Examiner's Signature

 

Medical Examiner's Telephone Number

 

 

Date Certificate Signed

 

 

 

 

 

 

 

 

 

 

 

 

Medical Examiner's Name (please print or type)

 

MD

Physician Assistant

Advanced Practice Nurse

 

 

 

 

 

 

 

 

DO

Chiropractor

Other Practitioner (specify)

 

 

 

 

 

 

 

 

 

 

 

 

Medical Examiner's State License, Certificate, or Registration Number

 

Issuing State

 

 

 

National Registry Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver's Signature

 

 

 

Driver's License Number

 

 

 

Issuing State/Province

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver's Address

 

 

 

 

 

 

 

 

 

 

CLP/CDL Applicant/Holder

 

Street Address:

City:

 

 

State/Province:

 

Zip Code:

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements.**

How to Edit Examiner Certificate Form Online for Free

Any time you want to fill out medical examiners certificate, you don't need to install any sort of applications - just try using our online tool. Our expert team is continuously endeavoring to develop the editor and help it become much easier for clients with its multiple functions. Capitalize on the current progressive possibilities, and discover a heap of unique experiences! If you are looking to get started, this is what it will require:

Step 1: Firstly, access the pdf editor by clicking the "Get Form Button" in the top section of this site.

Step 2: With the help of our state-of-the-art PDF tool, it is possible to do more than merely complete blank form fields. Edit away and make your docs look high-quality with customized text added, or adjust the original content to perfection - all supported by the capability to incorporate stunning photos and sign it off.

With regards to the blanks of this precise form, here's what you need to do:

1. For starters, when filling out the medical examiners certificate, beging with the page that contains the next blank fields:

medical certificate examiner conclusion process explained (portion 1)

2. Once your current task is complete, take the next step – fill out all of these fields - Drivers Signature, Drivers Address, Street Address, Drivers License Number, Issuing StateProvince, City, StateProvince, Zip Code, Yes, CLPCDL ApplicantHolder, and This document contains sensitive with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Step # 2 in completing medical certificate examiner

In terms of Issuing StateProvince and Drivers License Number, ensure you don't make any mistakes in this current part. Those two are the most significant ones in this document.

Step 3: Before finalizing the form, double-check that all blanks have been filled out the correct way. As soon as you believe it is all fine, click “Done." Download the medical examiners certificate the instant you join for a 7-day free trial. Quickly use the form in your FormsPal account page, with any edits and changes being conveniently synced! FormsPal offers protected form completion devoid of data recording or distributing. Feel safe knowing that your information is safe here!

Examiner Certificate Form isn’t the one you’re looking for?

Related Documents