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Dl9 medical form Stocks of the Medical certificate for driver licence DL9 are held by To keep the Driver Licence Register up-to-date the Transport Agency also operates an authorised information matching programme with Births Deaths and Marriages. Application for endorsement D F R T W DL19 Please read this before you start Check that you have all the relevant What to bring requirements from page 3 and ensure you have completed all questions - if not applicable write N/A. Application details 1. What type of application are you making Applying for an endorsement for the first time Applying to renew an endorsement Reapplying because your endorsement has been expired for more than five years Driver licence number Name 2. What is your New Zealand driver licence number 3. What is your name Surname Full first name Middle name s 4. Are the names you have shown on this application different from that shown on any of the supporting identification including any driver licence No Yes My previous name was 5. Are you Organ donation Male Female 6. Would you be willing to donate organs in the event of your death If you answer yes in the event of your death your next-of-kin will be asked for their agreement to donate organs. Please let them know of your wishes. Birth date What is your date of birth 8. Where were you born / Day Month Name of town/city Address Year Name of country 9. What address would you like printed on your licence None Physical address Mailing address 10. Where do you live Street number and name Suburb Town/city 11. What is your mailing address if different from above Giving your telephone numbers is optional* 12. What are your contact telephone numbers Home/mobile Work page 1 Continued on next page 12/14 Endorsement type 13. What type of endorsement s are you applying for D Dangerous goods endorsement T Tracks endorsement F Forklift endorsement You must hold a full Class 1 car licence before you can apply for any F R T or W endorsements. W Wheels endorsement R Rollers endorsement Medical fitness 14. Please tick if you have a medical condition that has affected your ability to drive safely in the last five years. See the Medical certificate section on page 4 to determine if you require a medical certificate. Please tick if you Examples of medical conditions that could adversely affect your ability to drive include diabetes double vision Alzheimers epilepsy fits head or spinal injuries high blood pressure amputations mental illness joints or limb problems stroke convulsions. You must provide a medical certificate with this application* Please see the Medical certificate section on page 4 for more information* have never been aware of or told by a doctor that you are aware of a medical condition but it has not affected your ability to drive safely in the past five years. have supplied a medical certificate in the past five years that is of the same medical standards as the class for which you are currently applying and Medication and treatments can also affect your ability to drive safely.

Eng1 medical form pdf MSF 4112 Rev 0818Seafarer Medical Report (ML5) and ML5 Certificate This form is for use by the following applicants only. Please tick why you need this form/certificate: 1. New applicant for an MCA

Eng1 medical form pdf 22334494 Club Yachting Logo Home Boats ... Course Information - Yachtmaster Coastal MCA Preparation and exam.pdf. 86.9 KiB 127 Downloads Details ... Category: Yachtmaster Useful forms ... MSF4112 - ML5.pdf

Special olympics medical form... Athlete Medical Form HEALTH HISTORY (pages 1 & 2 to be completed by the athlete or parent/guardian/caregiver) REGION/AREA: DELEGATION/TEAM: ATHLETE INFORMATION First Name:PARENTMiddle Name:GUARDIAN

Medical forms numeric listing... State of Illinois Department of Healthcare and Family ServicesAPPENDIX E3b BINAURAL HEARING AID QUESTIONNAIRE Patient NameRINBirth DateIn order to make an informed decision for coverage of a binaural

Medical form McKinney Independent School District Co-Curricular/Extracurricular Emergency Medical Form therefore McKinney ISD policies continue to be in effect. PLEASE NOTE If any medications are found on the student s person or in his/her possession he/she may be subject to disciplinary action. Signature of Parent or Guardian Date If parents cannot be reached in case of emergency please contact Name Phone Physician s Name Phone This health form is correct so far as I know and the person listed above has permission to engage in all prescribed activities except as noted. In case of injury or serious illness during any trip I hereby grant permission for school employees to secure medical services for the student named on this sheet. This includes policies for medication usage. The following guidelines are in effect for all secondary activities and trips. Student Name ID Grade Mother s Name Emergency number s Last First Address Home Phone Street City/State Zip Insurance Company Phone Name of Insured SS of insured Employer of Insured Please provide applicable numbers Certificate Number Group Number Payor Number Policy Number Health History Check give approximate dates if applicable Frequent ear infections Headaches Heart defects/disease Seizure disorder Bleeding/clotting disorders Hypertension Emotional disturbances Diseases Diabetes Sickle Cell Asthma Allergies Hay fever Poison ivy etc* Insect stings Other drugs Disabilities diseases chronic or recurring illness Current medication send with MISD medical form Any specific activities to be limited by physician advice Any medically prescribed meal plan or dietary restrictions Any known allergies food drugs plants insects etc* Dates of operations serious injuries psychiatric counseling or hospitalization Additional health information Co/Extracurricular Emergency Medical Form January 22 2009 4 00pm JAB Oral/Topical Medication Release No I. II. IV. V. Yes Anti-inflammatory / anti-pyretic Ibuprofen Advil etc* Acetaminophen Tylenol etc* Antacids / Anti-nausea Diarrhea TUMS Imodium AD Allergy Benadryl Topicals Bacitracin Caladryl Sunscreen Aloe Cough drops I authorize the supervising McKinney ISD employee to administer the above medication per package instructions. Any other medication OTC or prescription must be provided by the parent in the original container or package with a signed MISD medication form and adhered to MISD medication policy. Such treatment will be administered only by licensed medical personnel* I agree to accept responsibility for all authorized doctor hospital and medical expenses. This includes policies for medication usage. The following guidelines are in effect for all secondary activities and trips. Student Name ID Grade Mother s Name Emergency number s Last First Address Home Phone Street City/State Zip Insurance Company Phone Name of Insured SS of insured Employer of Insured Please provide applicable numbers Certificate Number Group Number Payor Number Policy Number Health History Check give approximate dates if applicable Frequent ear infections Headaches Heart defects/disease Seizure disorder Bleeding/clotting disorders Hypertension Emotional disturbances Diseases Diabetes Sickle Cell Asthma Allergies Hay fever Poison ivy etc* Insect stings Other drugs Disabilities diseases chronic or recurring illness Current medication send with MISD medical form Any specific activities to be limited by physician advice Any medically prescribed meal plan or dietary restrictions Any known allergies food drugs plants insects etc* Dates of operations serious injuries psychiatric counseling or hospitalization Additional health information Co/Extracurricular Emergency Medical Form January 22 2009 4 00pm JAB Oral/Topical Medication Release No I.

Kansas division of vehicles me... Page 1 of 2 PLEASE RETURN COMPLETED MEDICAL FORMS TO: PH: (785) 3688971 FAX: (785) 2965857STATE OF KANSAS DIRECTOR OF VEHICLES MEDICAL/VISION UNIT 300 SW 29th ST. PO BOX 2188 TOPEKA KS 666012188 KANSAS

Medical forms to 4. Specify any driving restrictions that are appropriate based on the patient s disease or medical and/or psychological condition. 5. 3. Please note that if the patient has had a recent loss or alteration of consciousness the exam date must be a full six months after the date of the last occurrence. SECTION I PHYSICIAN S REPORT In your opinion does this patient have a medical condition that could affect the patient s ability to safely operate a motor vehicle Yes No Uncertain If yes or uncertain please explain Has the patient had any loss/lapse of consciousness seizure activity fainting or syncopal event in a waking state If yes please indicate the date of the last occurrence MM/DD/YYYY Was the seizure or loss of consciousness an isolated incident Should this patient be referred to a specialist such as a neurologist or psychologist to determine their ability to safely operate a motor vehicle If yes what type Page 1 of 2 Physician s Comments Indicate below which restrictions may apply to the patient s license if issued or continued Maximum 6 restrictions. PLEASE RETURN COMPLETED MEDICAL FORMS TO PH Telephone 785 368-8971 FAX FAX 785 296-5857 STATE OF KANSAS DIRECTOR OF VEHICLES MEDICAL/VISION UNIT 915 HARRISON STREET PO BOX 2188 TOPEKA KS 66601-2188 KANSAS DIVISION OF VEHICLES MEDICAL FORM GENERAL INFORMATION HISTORY TO BE FILLED OUT BY THE PATIENT NAME DRIVER LICENSE DOB ADDRESS CITY/STATE/ZIP PHONE Currently enrolled in Driver s Education YES / NO If yes instructor name phone number RELEASE OF INFORMATION Permission is granted for release of all medical information concerning me to the Kansas Division of Vehicles by all medical professionals filling out this form. SIGNATURE OF PATIENT DATE To the Medical and/or Psychological Professionals Please complete the sections of this report applicable to this patient s conditions. All treating physicians must complete a set of forms. If you have questions please call 785-368-8971. Corrective Lenses Within City Limits Mechanical Aid Daylight Hours Only Licensed Driver in Front Seat Prosthetic Aid No Interstate Driving Outside Business Area Automatic Transmission Outside Mirror Miles From Home 5-30 in 5 mile increments Should an actual test of the patient s driving ability be administered Should an annual medical report be required to be filed with the Division of Vehicles This patient is capable of safely operating a motor vehicle. 2. Indicate yes or no whether from a medical and/or psychological standpoint only this patient is capable of safely operating a motor vehicle. The information on this form must be from an examination within the last 90 days. Instructions 1. Please answer each question and fill out the entire form carefully and legibly. You assume no responsibility in making this report other than that of truthfully representing the facts as they appear in your professional judgment. Driver must be considered a safe candidate in order to request a drive test. Does this patient require a vision exam Name of Medical Professional License Please print Date of Examination Medical Professional s Specialty Signature of Medical Professional Address Date Signed Phone.

Ct dmv medical form MEDICAL FORMSTATE OF CONNECTICUT DEPARTMENT OF MOTOR VEHICLES 60 STATE STREET, WETHERSFIELD, CT 061611013 DRIVER SERVICES DIVISION ct.gov/dmvP142M Rev. 220Department of Aging and Disability Services

Cdl self certification medical... MINNESOTA DEPARTMENT OF PUBLIC SAFETYPrint FormDRIVER AND VEHICLE SERVICESC o mme rci al D riv e r License M edical Self cer tif ication Form Instructions:All commercial driver\'s license (CDL) holders,

Ct dmv medical form 488302457 STATE OF CONNECTICUT DEPARTMENT OF MOTOR VEHICLES 60 STATE STREET, WETHERSFIELD, CT 061611013 DRIVER SERVICES DIVISION ct.gov/dmvMEDICAL FORM P142M Rev. 718Department of Rehabilitation Services/ Driver

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