MEDICAL DECLARATION On March 3rd, 1999 Transport Canada and the US federal Highway administration (FHWA) entered into a reciprocal agreement regarding the physical requirements for a Canadian drivers of a commercial vehicle in the US, as currently contained in the federal Motor carriers safety regulation, part 391.41 et seq, and vice-versa, the reciprocal agreement will remove the requirements for a Canadian driver to carry a copy of a medical examiners certificate indicating that the driver is physically qualified to drive (In effect, the existence of a valid driver’s license issued by the province of Alberta is deemed to be proof that a driver is physically qualified to drive in US) however, FHWA will not recognize an Alberta license if the driver has certain medical conditions and those conditions would prohibit them from driving in the US. I certify that I am qualified to operate a commercial vehicle in the United States. I further certify that: A) I have no clinical diagnosis of diabetes currently requiring insulin for control B) I have no established medical history or clinical diagnosis of epilepsy C) I don’t have impaired hearing (A driver must be able to 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 does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 100 Hz, or 200 Hz with or without a hearing aid when tested by an audiometric device calibrated to American National Standard Z24.5-1951) D) I have not been issued a waiver by the province of Alberta allowing me to operate a commercial vehicle pursuant to section 20 or 22 of the Alberta regulation 340/94 I further to inform SUNRISE FREIGHT should my medical status change, or if I can no longer certify conditions A to D, described Driver’s Name (Printed): Driver’s Signature: Witness: Date:
MEDICAL DECLARATION On March 3rd, 1999 Transport Canada and the US federal Highway administration (FHWA) entered into a reciprocal agreement regarding the physical requirements for a Canadian drivers of a commercial vehicle in the US, as currently contained in the federal Motor carriers safety regulation, part 391.41 et seq, and vice-versa, the reciprocal agreement will remove the requirements for a Canadian driver to carry a copy of a medical examiners certificate indicating that the driver is physically qualified to drive (In effect, the existence of a valid driver’s license issued by the province of Alberta is deemed to be proof that a driver is physically qualified to drive in US) however, FHWA will not recognize an Alberta license if the driver has certain medical conditions and those conditions would prohibit them from driving in the US. I certify that I am qualified to operate a commercial vehicle in the United States. I further certify that: A) I have no clinical diagnosis of diabetes currently requiring insulin for control B) I have no established medical history or clinical diagnosis of epilepsy C) I don’t have impaired hearing (A driver must be able to 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 does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 100 Hz, or 200 Hz with or without a hearing aid when tested by an audiometric device calibrated to American National Standard Z24.5-1951) D) I have not been issued a waiver by the province of Alberta allowing me to operate a commercial vehicle pursuant to section 20 or 22 of the Alberta regulation 340/94 I further to inform SUNRISE FREIGHT should my medical status change, or if I can no longer certify conditions A to D, described Driver’s Name (Printed): Driver’s Signature: Witness: Date:
DRIVERS_APPLICATION_FOR_EMPLOYMENT-NEW.docx