____________________(Name of driver)
____________________(SS No.)
____________________(Signature of driver)
I certify that the above named driver, as defined in § 390.5 , is a single-employer driver driving a commercial motor vehicle operated by the below named carrier and is fully qualified under part 391, Federal Motor Carrier Safety Regulations. His/her current medical examiner's certificate expires on ______(Date).
This certificate expires:
(Date not later than expiration date of medical certificate)
Issued on______(date)
Issued by__________
(Name of carrier)
(Address)
(Signature)
(Title)
49 C.F.R. §391.65