This document is a Medical Examiner's Certificate for Commercial Driver Medical Certification. It includes a public burden statement regarding the requirement to respond to the collection of information, which displays OMB Control Number 2126-0006. The certificate contains sections for the medical examiner's information and the CMV driver information. The medical examiner's section includes their telephone number, driver's license number, issuing state, signature, and driver's signature, among other details. The CMV driver information section includes their issuing state or province, revocation date, and various checkboxes for certifying the driver's qualification based on federal and state regulations, as well as any necessary accommodations or exemptions.
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