Fill and Sign the Medical Waiver 497332359 Form

Commercial Driver License Intrastate Medical Waiver Application If you are a commercial driver and do not meet minimum medical standards, you may use this form to apply for an intrastate medical waiver. This form must be filled out by you and your medical examiner. Mail or fax this completed application with a copy of your physical exam form to: CDL Program, Department of Licensing, Post Office Box __________, ___________________ (Name of City) , ______________ (Name of State) , ________________ (Zip Code) , and __________________ (Fax Number) , Allow __________ (number) to ___________ (number) days for processing. If you have additional questions, please call ______________________ (Phone Number) .  Print or Type Driver’s name (Last, First, Middle initial):__________________ ________________________________________________________________  Driver license number: ____________________________________  Date of birth: _______________________  Residence address: _____________________________________________  Telephone Number with Area Code: ______________________________  Mailing address:_____________________________________  City: ________________ State:______________ Zip Code: ________________ Description of medical condition(s) the waiver is being requested for: ____________ ____________________________________________________________________ Certification I certify under penalty of perjury under the laws of the state of ___________________ (name of state) that the foregoing is true and correct. I understand that false statements on this application may result in cancellation of my commercial driving privileges. Witness my signature this the ______ day of _______________, 20_____. ___________________________ (Printed Name of Driver) ___________________________ (Signature of Driver) Medical This section must be completed by a licensed medical doctor (MD), a doctor of Osteopathy (DO), a board certified physiatrist (doctor of physical medicine), or an orthopedic surgeon. Print or Type Medical Examiner’s Name and Title: Name: ________________________ Title: _____________________  Telephone number including area code: ____________________________  Office: ______________________________________________________ Certification  The above driver’s medical condition is not likely to interfere with the ability to safely operate a commercial motor vehicle and is likely to remain stable for: [ ] The next two years other____________________________________ [ ] Not more than two years [ ] Other ____________________________________ ______________ Witness my signature this the _______ day of ______________, 20_____. ____________________________ (Printed Name of Medical Examiner) ____________________________ ____________________________ (Name and Title of Medical Examiner) For Department Use Only  CDL License: ____________________  Issued: ________________________  Applied for: _______________________  DOT expiration: _________________________  Waiver expiration: _________________________ The Department of Licensing has a policy of providing equal access to its services. If you need special accommodation, please call (Phone Numbers) ________________ or ___________________.