Form MCSA5876 (Revised: 12/06/2015) OMB No-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the driver's last and first name in the designated fields at the top of the form.
3. Select the appropriate checkbox to indicate whether the examination was conducted under Federal Motor Carrier Safety Regulations or with applicable State variances.
4. If applicable, check any conditions that apply, such as wearing corrective lenses or having a waiver/exemption.
5. The medical examiner must then provide their signature, telephone number, and printed name in the specified areas.
6. Fill in the expiration date of the Medical Examiner's Certificate and the date when it was signed.
7. Complete additional details regarding the medical examiner's credentials, including their state license number and national registry number.
8. Finally, have the driver sign and provide their driver's license number along with their address information.

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