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Form MCSA-****

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~Bll'del ~~ conduct or spoosor, and II pen,on·ls nol required 'to ·~pond to, nor shall a pen:o;, be subject to a penalty,for failure to comply with,a coilection of information subject to the r uir 0MB No.: 2126-0006 Expiration Date: 03/31/2025

Redudion Act unless that collection of~etion ~ys.e'CU~nt ~lid 0MB ~ontrol .~u r. The 0MB Conlrol,N'!mber f~ !~is information coll~ion i;1212~g<JJ1 fc reporting for this eollecti~ o(~~ents of~ Pa~rwork approximately one minute per ~ -~,ng the time tor revrewmg _mstrud,C?ns •. g~th~ ng. ~e .~ata n~ed~, and _c~meleting and reviewing the collection <?f,mf¥naii_on. All responses fo this collection of . ormat,o~ •~_estin;iat,,d to be· m Send MC-RRA. commentsreg&1200 NewJerseyAvenoe.rding this bu!den -SE. estimate Washington. or any .other 0 C 20590 aspect of ·• thrs collection of information, ., 1ncludrng suggestions .,. for ' reducihg • this' burden ·• • · to: lnformation,, .. ~-Colfecti6n -~• '• Clearance . Officer •· Federal u~-muwr - Carner rnf ation Safety are Administration mandatory.

• • . .. .. : . : " f", _ • Federal U.S.Departmento~Tnmsportation MolDr Carner MEOICAL EXAMINER'S CER;~- rlFICATE' ~- . Safety Adminis1ralion (for Commercial Driver Medical Certification) ·• CMV DRIVER CERTIFICATION

I certify that I have examined (last name) ---Diaz -Uzcanga --_-_ -- (lirstnams) 0 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 O the person Federal is qualified, Motor Carrier and, if Safety applicable, Regulations only when (49 (CFR check 391.all 41-that 391.apply)49) ". with any applicable State variances (which will only be valid for intrastate operations), and, with knowledge of the driving duties, 1 find this Jose in accordance with (please check only one).

@Wearing corrective lenses O Accompanied by a waiver/exemption (specify type): D Driving within an exempt intracity zone (49 CFR 391.62) (Federal} O Wearing hearing aid D Accompanied by a Skill Performance Evaluation (SPE) Certificate D Qualified by operation of 49 CFR 391.64 (Federal} D Grandfathered from State requirements (State)

The information I have provided regarding this physical examination is true and complete. A complete Medical Examination Repon Form. MCSA-5875, witfJ any attachments embodies my findings completely and correctly, and is on file in my office. lllledical Examiner's Certificate Expiration Date

09118/2024

MEDICAL EXAMINER INFORMATION

I • s Signature

Examiner's Name (please print or type)

Bisbee, Cheryl

Medical Examiner's State License, Certificate, or Registration Number 085.00451 1

CMV DRIVER INFORMATION

Street Address: 1300 n. 4th street #208

City: Milwaukee

Medical Examiner's Telephone Number

{630-***-****

Date Certificate Signed

09118/2023

0 MD 0 Physician Assistant

0 DO O Chiropractor

Issuing State

0 Advanced Practice Nurse

IL

Driver's License Number

D2254216729700

0 Other Practitioner (specify) _

National Registry Number

244*******

Issuing State/Province

WI

This document contains sensitive info · . -. . . . . . . . . . . . - prevent inadvertent di b rmatJon a

nd

is for official use only. Improper hand/mg of this 111/ormallon could negallvely affect tndividua/s. Handle and secure this mfonnat1on appropnately to sc osure r keepmg the documents under the control of authorized persons. Properly dispose of this document when 110

longer required IP be maintained by regulatory requirements. State/Province: WI Zip Code: ~12

CLPICDL

0Yes ONo

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