*Please print this page and the next page 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your last name, first name, middle name, date of birth, and social security number in the designated fields.
3. Fill in your address details including street, city, state, and zip code.
4. The physician will need to complete the medical examination section. Ensure they check either 'Passed' or 'Failed' based on their assessment.
5. Your physician should provide their name, state license number, mailing address, office phone number, and sign the document.
6. Review all entered information for accuracy before saving or printing the completed form.

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