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Form 396 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the applicant's last name, first name, and middle initial in the designated fields. Ensure accuracy as this information is crucial for identification.
- Fill in the applicant/operator docket number and facility details. This includes the facility name and its corresponding docket number, which can be separated by a semicolon if there are multiple.
- In Section A, provide medical exam information including the physician's printed name, certification date, license number, and state of licensure. Make sure to check the appropriate guidance document used for assessment.
- Review and select any necessary restrictions based on the physician’s recommendations. For each selected restriction, provide explanations in the designated box below.
- Complete Sections B and C by signing where indicated. The applicant/operator must sign in black ink, followed by a senior management representative's signature certifying the information provided.
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Related links
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