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Get MCSA-5876 2018

Form MCSA-5876 OMB No. 2126-0006 Expiration Date 8/31/2018 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 failure to comply with a collection of information subject to the requirements 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 1 minute per response including the time for reviewing instructions gathering the data needed and completing and reviewing the collection of information* All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to Information Collection Clearance Officer Federal Motor Carrier Safety Administration MC-RRA 1200 New Jersey Avenue SE Washington D*C* 20590. Medical Examiner s Certificate U*S* Department of Transportation Federal Motor Carrier Safety Administration for Commercial Driver Medical Certification I certify that I have examined Last Name First Name in accordance with please check only one 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 I find this person is qualified and if applicable only when check all that apply Wearing corrective lenses Wearing hearing aid Accompanied by a waiver/exemption Driving within an exempt intracity zone 49 CFR 391. 62 Federal Qualified by operation of 49 CFR 391. 64 Federal Grandfathered from State requirements State The information I 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. Date Certificate Signed MD Physician Assistant Advanced Practice Nurse DO Chiropractor Other Practitioner specify Issuing State National Registry Number Driver s Signature Driver s License Number CLP/CDL Applicant/Holder Driver s Address Street Address City State/Province Zip Code Yes No. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 1 minute per response including the time for reviewing instructions gathering the data needed and completing and reviewing the collection of information* All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to Information Collection Clearance Officer Federal Motor Carrier Safety Administration MC-RRA 1200 New Jersey Avenue SE Washington D*C* 20590. .

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