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

Form NameExaminer Certificate Form
Form Length1 pages
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

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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


Federal Motor Carrier


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



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)



Physician Assistant

Advanced Practice Nurse











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:






Zip Code:




















**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.**

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