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MEDICAL EXAMINER'S CERTIFICATE.

(for Commercial Driver Medical Certification)

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[craw DRIVER CERTIFICATION

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© tre Federal Mater Carter Safety Regulations (49 CFR 381 41:39 £9) and, wit knowledge othe diving des, nds perton is qualified, and, appicable, Gly when (check a ht app) On

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waiverlexemption (specify type) Clorivng wit

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— Ciranetathered trom State requirements (State)

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MEDICAL EXAMINER INFORMATION

ners Signature Medical Examiners Telephone Number Date Cerificate Signed

314-***-**** 101*******

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Medical Examiner's State License, Certificate, or Registration Number Issuing State ‘National Registry Number

P08 _ Mo 264-***-****

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CMV DRIVER INFORMATION

“a Driver's License Number Issuing State/Provinco

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