MEDICAL CERTIFICATION FORM For-Hire Operator Renewing

(THIS IS REQUIRED TO MAINTAIN YOUR LICENSE)

Physician’s Last Name, First Name Physician’s Signature

Number & Street (Mailing Address) Physician’s License #

City State Zip Code State in which Physician is licensed

Phone# ( ) ________-_______________

Official Stamp Required

THIS FORM MUST BE VALIDATED WITH AN OFFICIAL STAMP BY PHYSICIAN.

it is my opinion that s/he:

is medically fit to safely operate a TLC licensed vehicle.

is not medically fit to safely operate a TLC licensed vehicle.

_______________________________________________________________________________________________________

FHV Renewal - Medical Form 11.16.15

Per Section 19-505(d) of the Administrative Code of the City of New York all For-Hire Operator License applicants were required to submit a medical

form which indicates that they are fit to safely operate a TLC licensed vehicle. As this form was not initially collected when your application for licensure

was accepted and processed you must now submit this form with your upcoming renewal in order to renew your license. This is a one-time submission.

You must submit this form in addition to all other requirements of licensure in order to renew your license. Failure to submit this form by the time your

license expires will result in the non-renewal of your license. The form must be an original form signed and dated by a licensed Doctor.

Medical Exam Requirements

· You must submit this original form with your renewal.

· Failure to submit this form by your expiration date will result in the denial of your license renewal.

· This form must be completed, signed and stamped by a licensed doctor. No other form can be used or will be accepted.

· The date of the examination cannot be more than ninety (90) days prior to the date you submit your renewal.

(date of exam)

(name of applicant)

This is to certify that I have examined

the applicant for a NYC Taxi and Limousine Commission TLC Driver’s License Renewal bearing license

number, on , and based on my examination reported herein,

(TLC license #)

MEDICAL CERTIFICATION FORM

For-Hire Operator Renewing Applicants

Please visit our website for more information at: www.nyc.gov/tlc, or our office at 31-00 47

Avenue,

Floor, Long Island City, NY 11101 or contact our Call Center at 718-391-5501.