Form FMCSA-5875 – The DOT Np

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Form FMCSA-5875

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First Name

Last Name

Birthdate

Age

Street

City

State / Province

Zip Code

Driver's License Number

Issuing State Province

Phone

Gender

Male Female

CLP/CDL Applicant/Holder

Yes No

Has your USDOT/FMCSA medical certificate ever been denied or issued for lessthan 2 years?

Yes No Not Sure

Have you ever had surgery? If "yes," please list and explain below.

Yes No Not Sure

Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? If "yes," please describe below.

Yes No Not Sure

Driver's resources

What To Expect AT DOT Exam
DOT Disqualifying Conditions
Exemption Program

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Form FMCSA-5875
About Us
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Contact Us

Services

Point of care Glucose
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Urine dip
Driver’s permit physicals

Contact info

Instructor: Naeemah Selby CRNP

523 Belthleham pike Glenside, PA. 19038
thedotnp@gmail.com
570-669-8826

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