Form Mr 5 is an important form that companies use to file their annual reports. This form allows the public to track a company's financial performance and assess their potential risk. The form must be filed by May 15th each year, and provides detailed information about the company's assets, liabilities, and shareholders' equity. Failing to file can result in significant fines and penalties. So if you're a business owner, make sure you know what Form Mr 5 is and how to complete it accurately.
| Question | Answer |
|---|---|
| Form Name | Form Mr 5 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | undersigned, undergo, New_Jersey, DOB |
MOTORVEHICLE COMMISSION
Medical Fitness Review Unit
P.O. Box 173
Trenton, New Jersey
DRIVER EXAMINATION AND/OR MEDICAL EVALUATION REQUEST
The undersigned recommends that the New Jersey licensed driver (named below) submit to a driver reexamination and/or evaluation.
D.L. NUMBER: |
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CLASS: |
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ENDR: |
RESTR: |
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DOB: |
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EXPIRES: |
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NAME:
ADDRESS:
CITY/STATE/ZIP:
SEX: EYES: HT:
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Reexaminationmay be required of drivers in the categories below. Please check any that apply to this driver:
1. Persons having mental OR physical disorders which may affect their ability to safely operate a motor vehicle;
2. Persons involved in a traffic accident resulting in a fatality where a violation of any of the provisions of N.J.S.A.
3. Persons who have accumulated 12 or more points as provided in N.J.A.C.
4. Persons convicted of violating any of the provisions of N.J.S.A.
I have reason to believe that this driver should submit to a reexamination and/or medical evaluation because of the information on the reverse side of this form.
Signature |
Badge Number/Court Code |
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Title
(please print or type)
Full Name
Police DepartmentICourt
Address
City |
Phone Number |
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Officer's Name:
Driver's Name:
Date(s) of Incident(s)
Was driver charged with any Motor Vehicle violations?
No |
Yes |
If yes, provide statute(s) code(s) and summons number(s). |
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Did an accident occur? No
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Yes |
If yes, attach copy of your accident report, including narrative or diagram. |
Upon Questioning,did the driver admit to any physical problems or medical conditions?
No |
Yes |
If yes, indicate statements |
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Have you had any contacts with the driver?
No |
Yes |
If yes, describe circumstances of contact. |
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In the space below, provide a narrative that describes why you believe that this driver should undergo a reexamination or medical evaluation. If the source of the information provided below IS someone other than yourself, provide that observer's name, full address and the telephone number where the observer can be contacted during normal working hours. If the driver contests the need for reexamination or medical review, you and/or any observers/witnesses may be subpoenaed to testify at an administrative hearing related to this matter.