Driver
Resume:
FOrMm MLOA- ****
Public Burden Statement
A Federal agency may not conduct or sponsor, and a person is Not required to respond to, nor shall a person be subject to a penalty for farlure to comply with a collection of information subject to the requirernents of the Paperwork Reduction Act unless
that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006, Public reporting for this collection of information is estimated to be approximately minute per response,
induding the time for renewing instrucbons, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory Send comments Tegarding this burden estimate or ary A
R) other aspect of this collection of information. includina suaaestions for reducina this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA. 1 200 New Jersev Avenue. SE. Washmaton DC 20590
Medical Examiner's Certificate
(for Commercial Daver Medical Certification)
US Department of Tramperation
Federal Motos Carrer
Salety Admewumanen
I certify that Ihave examined Last Name: Bahati First Name: Fiston in accordance with (please check only one)
@ the Federa! 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 Federal Mator Carrier Safety Regulations (49 CFR 391.41-391,49) with any applicable State variances (which will only be valid for intrastate operations). and, with knowledge of tne driving duties,
I find this person is qualified, and, if applicable, only when (check all that apply):
O Driving within an exempt intracity zone (49 CFR 391.62) (Federal)
Qualified by operation of 49 CFR 391.64 (Federal)
O Grandfathered from State requirements (State)
0 Accompanied bya waiver/exemption
O Wearing corrective lenses
(Accompanied by a Skill Performance Evaluation (SPE) Certificate
O Wearing hearing aid
Medical Examiner's Certificate Expiration Data
12/30/2023
Date Certificate Signed
12/30/2021
The information have provided regarding this physical examination is true and complete. A complete Medical Examination Report Form,
MCSA-5875, with any attachments embodies my findings completely and correctly, and is on file in my office.
Medical Examiner's Telephone Number
Ramirez, Richard
Medical Examiner's State License, Certificate, or Registration Number
Street Address
1916 Poin: Breeze Ave
@mod O Physician Assistant
Opbo O Chiropractor
Issuing State
KY
Driver's License Number
31993290
O Advanced Practice Nurse
O Other Practitioner (specify)
National Registry Number
Issuing State/Province
PA
TEE ne
City, Philadelphia State/Province: PA
_
CLPICDL ApplicantHolder
Zip Code: 19145 @ves ONo
Contact this candidate