10Medical Practitioner Certification#

To be completed by a Doctor#

Refer to the Medical Guidelines - see opposite I have examined the applicant having regard for the health and safety of the public generally, and state that the applicant:

• is mentally and physically an appropriate person to hold an approval
• is not mentally and physically an appropriate person to hold an approval

Doctor’s name (please print) Address or stamp Telephone number Doctor’s signature SIGN Date of examination / /

To be completed by an Optometrist#

Refer to the Medical Guidelines - see opposite I have examined the applicant having regard for the health and safety of the public generally, and state that the applicant:

• has suitable vision to perform traffic controller duties
• does not have suitable vision to perform traffic controller duties

Optometrist’s name (please print) Address or stamp Telephone number Provider number Optometrist’s signature SIGN Date of examination / /