Medical Examiner's National Registry Verification - Snap-Out Format

Forms are 2-ply, carbonless, 8-1/2" x 11-3/4".
758FSC2 (27034)
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The Final Rule published April 20, 2012 requires the motor carrier to verify that the medical examiner was qualified to conduct a CDL driver's physical exam. This form meets that requirement.
•Helps you comply with DOT's 49 CFR §391.23 and §391.51
•Form can be used now, though it s required to be used as of May 21, 2014
•Includes fields to enter the following information:
◦Driver's Name and Identification Number
◦Medical Examiner and National Registry Number
◦Motor Carrier and Location
◦Motor Carrier Representative Signature and Date
•Snap out format
•Two plies
•Measures 8-1/2" x 11-3/4"