QUALIFICATIONS OF INTRASTATE
DRIVER CERTIFICATION AND EXEMPTION
CDL-5 (Rev. 11/02)
All information on this form except the signature must be TYPEWRITTEN or PRINTED in BLACK INK.
The signature shall be WRITTEN in BLACK INK.
In order to obtain a commercial driver license which authorizes the operation of a commercial motor vehicle in intrastate commerce, you
must certify to and meet the following qualifications as taken from 49 Code of Federal Regulations (CFR), Part 391, and the Texas
Transportation Code, Chapter 522.
Intrastate commerce is the transportation of property (a commodity) where the point of origin and destination are totally within one state
and no state line or international boundary is crossed. The Bill of Lading will be an indicator as to whether a shipment or commodity is
interstate or intrastate. If there is no Bill of Lading, the origin and destination of the shipment will be an indicator.
I certify that I:
a. Am at least 18 years of age
b. Am not disqualified to drive a motor vehicle.
I further certify that I: (check the appropriate box)
a. Am a driver who operates a commercial motor vehicle in intrastate commerce, not transporting property requiring
a hazardous material placard, and was regularly employed operating a commercial motor vehicle in Texas
prior to August 28, 1989 and am not required to meet the medical standards set forth in the Federal Motor
Carrier Safety Regulations.
Drivers who claim this exemption and who are seeking to obtain or maintain employment as a school bus driver
must undergo and pass an annual physical examination as required by V.C.S. Article 6687b, Section 5(a),
recodified as Texas Transportation Code Ann., Section 521.022 (1996).
b. Meet the physical qualifications of 49 CFR, Part 391, as follows:
1. Have no loss of a foot, a leg, a hand, or an arm, or have been granted a waiver;
2. Have no impairment of: i. A hand or finger which interferes with prehension or power grasping; or
ii. An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a
motor vehicle; or any other significant limb defect or limiation which interferes with the ability to perform
normal tasks associated with operating a motor vehicle; or have been granted a waiver.
3. Have no established medical history or clinical diagnosis of diabetes melitus currently requiring insulin for control;
4. Have no current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency, thrombosis, or any other cardiovascular disease of a variety known to be accompanied by suncope, dyspnea, collapse, or congestive cardiac failure.
5. Have no established medical record history or clinical diagnosis of a respiratory dysfunction likely to interfere with my ability to control and drive a motor vehicle safely;
6. Have no current clinical diagnosis of high blood pressure likely to interfere with my ability to operate a motor vehicle safely;
7. Have no established medical history or clinical diagnosis of rheumatic, arthritic, orthopedic, muscular, neuromuscular, or vascular disease which interferes with my ability to control and operate a motor vehicle safely;
8. Have no established medical history or clinical diagnosis of epilepsy or any other condition which is likely to cause
loss of consciousness or any loss of ability to control a motor vehicle;
9. Have no mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with my ability to drive a motor vehicle safely;
10. Have distant visual acuity of at least 20/40 (Snellen) in each eye without corrective lenses or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, field of vision at least 70º in the horizontal Meridian in each eye, and the ability to recognize the colors of traffic signals and devices showing standard red, green, and amber; or have been granted a waiver. (OVER)
LAST NAME FIRST NAME MIDDLE NAME MAIDEN NAME
DRIVER LICENSE NUMBER BIRTH DATE SOCIAL SECURITY NUMBER
MO. DAY YEAR AGE NOW
11. First perceive a forced whispered voice in the better ear at not less than 5 feet with or without the use of a hearing aid or, if tested by use of an audiometric device, do not have an average hearing loss in the better ear greater than 40 decibels at 55 Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid when the audiometric device is calibrated to American National Standard (formerly ASA Standard) Z24.5-1951.
12. Do not use a Schedule I drug or other substance, an amphetamine, a narcotic, or any other habit forming drug; and
13. Have no current clinical diagnosis of alcoholism.
I CERTIFY THAT I HAVE READ, UNDERSTAND AND MEET THE PRECEDING QUALIFICATIONS FOR COMMERCIALMOTOR VEHICLE
DRIVERS IN INTRASTATE COMMERCE. I FURTHER CERTIFY THAT I WILL OPERATE A COMMERCIAL MOTOR VEHICLE IN
INTRASTATE COMMERCE ONLY.
Write Usual Signature
Sworn to and subscribed before me on this ________ day of _________________________, _______
Notary Public or Authorized Officer
DEPARTMENT USE ONLY
Waiver Presented:
( ) LIMB
( ) VISION
_________________________________________________________________________

DL-63 (Rev. 7/02)
EXPLANATION FOR EYE SPECIALIST
All applicants taking a driver’s license examination in Texas are given simple vision tests. Any applicant who may
need more accurate measurement; and any applicant who fails to meet the acuity score listed below is referred to an
eye specialist.
BEST EYE POOREST EYE ONE-EYED
Without Glasses 20/40 20/25
With Glasses 20/70 20/70
A report from a specialist is particularly valuable if the fitness of a driver is questioned in court, or following an accident.
In some cases examination by more than one specialist is requested.
When wide variations occur in acuity scores, the examining officer will appreciate the opportunity of discussing same
with you in order to improve the accuracy of our vision tests.
Please sign this report and list your own driver’s license number. Also for proper identification please have the person
examined sign the report in your presence.
If the case is an unusual one any additional comments which you may have will be appreciated. If needed, attach a
separate sheet to this report. The specialist assumes no responsibility in making this report other than that of truthfully
representing the facts.
The specialist will please check all applicable items:
1. Eye conditions present: a. Hyperopia b. Myopia c. Astigmatism d. Presbyopia e. Cataract
f. Traumatic Condition g. Suppression h. Poor Night Vision i. Strabismus
j. Poor Color Perception (k. Red l. Green m. Yellow) n. Other
2. Corrective lenses are being fitted for distant vision.
3. Corrective lenses will not improve distant vision.
4. Applicant would not accept corrective lenses.
5. Corrective lenses should not be worn for distant vision, because
6. Regardless of a qualifying acuity score corrective lenses should be worn for distant vision because
7. Applicant should drive in daylight only.
8. Other treatment to improve vision is recommended.
9. Due to permanent eye condition, applicant need not be referred for visual reexamination at next renewal of driver’s
license.
10. Other
over
INSTRUCTIONS TO APPLICANT
The simple vision test on the drivers license examination shows that you would probably be a safer driver if you
could see better. You are being asked to have your eyes examined by an eye specialist to determine whether
your sight can be improved by glasses or treatment. If glasses will make you a safer driver, your license will permit
you to drive only while wearing them.
In some cases examination by more than one specialist may be requested.
If you have any questions about how well you must be able to see to be granted the privilege of driving on the
streets and highways of Texas, the examining officer will be glad to answer them.
TEXAS DEPARTMENT OF PUBLIC SAFETY
DRIVER’S LICENSE
FULL NAME
OF
EXAMINEE:
ADDRESS:
CERTIFICATION OF SPECIALIST
I, certify that I have personally
examined the eyes of the above named, that a true record of my examination
appears here on and that he or she signed below in my presence.
SIGNATURE OF
SPECIALIST:
BUSINESS
ADDRESS:
TELEPHONE DRIVER’S
NO. LICENSE NO.
DATE OF EXAMINEE’S
EXAMINATION DRIVER’S LIC. NO.
SIGNATURE
OF EXAMINEE:
REPORT OF EXAMINER
ACUITY RIGHT EYE LEFT EYE BOTH EYES
WITHOUT GLASSES 20/ 20/ 20/
WITH PRESENT GLASSES 20/ 20/ 20/
COLOR Normal ( ) Red ( ) Green ( ) Amber ( )
SIGNATURE OF
EXAMINER
REPORT OF VISION SPECIALIST
ACUITY RIGHT EYE LEFT EYE BOTH EYES
WITHOUT GLASSES 20/ 20/ 20/
WITH PRESENT GLASSES 20/ 20/ 20/
WITH BEST CORRECTION 20/ 20/ 20/
COLOR Normal ( ) Red ( ) Green ( ) Amber ( )
FIELD OF VISION
TO RIGHT OF POINT OF FIXATION
TO LEFT OF POINT OF FIXATION
TOTAL ANGLE
over

from katrine elizabeth sackett32463 whitelady 5'21/2 5'3
7101 n ih 35 austin texas by burger king
oct 312018
information found in internet under google

Views: 
972
Post type: 
Author: 
training time
Business or Product name: 
Address: 
7101 North Interstate 35 Frontage Road
Austin, TX 78752
United States