Truck driver

the Fever Matoe Came fey Regulations (** CER ***,*1:19149) and with knowledge of the ving tes, fd his person x qa anf

(C the Fodeent Mosor Carer Safety Regulations -391,49) with any applicable State variances (Which will only be valid for intrastate operations),

Rinwfithés persion is qualified, and if applicable, only when (chack all that apply):

1a ps areca [] Accompanied by a waiver/exemption C) Driving within an exempt intracity zone (49 CPR 391.62) (Fedora)

ED Wenning bearing aid {C] Accompanied by a Skil! Performance Evaluation (SPE) Certificate (0) Qualified by operation of 49 CER 391,64(Federal)

(0) Grandfathered from State requirements (State)

physical examination is true and complete. A complete Medical Examination Report Form,

. and is on file in my office.

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