Cdl A Carrier

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\certy that have examined Last NSA cordance wth (please checkonly one

Federal Motor Carrier Safety Regulations (49 CFR 391,41-391.48) and, with knowledge of the driving duis find this ‘ron is qualified, and, f applicable, only wen (check all thatapply) OR

Othe Federal Motor Carrer Safety Regulations (49 CER 391,41-39149] wth any appabe Stat vaances wich wl ony be vl for nrastate operations) 2nd with kne-ledge of the driving duties,

find this person is qualified, and, if applicable, only when (check all that apply:

1D Wearing corrective lenses] Accompanied by a wsivereremtion

[i Wearing hearingaid Accompanied by Skil Performance Evakation(SPE) Cerificate] Qualified by operation of 42 CER 29164 (Federal)

1 Grandfathered from State requirements (Stare)

1D Driving within an exempt intracity zone (49 CER 391,62) (Federa))

MCSA-5875, with any attachments embodies my findings completely and correctly, andisn

Medical Exaniner’s Ce7ficate Expiration Date

“The information have provided regarding this physical examination is true and complete. A omplete Medical Examination Report Form, 5) 14

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