Division Of Motor Vehicles Wv Commercial Driver Licensee Medical Self-Certification Affidavit

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DMV-CDL-3
REV 1/13
West Virginia Department of Transportation
Division of Motor Vehicles
WV DMV
PO Box 17010
Charleston, WV
WV Commercial Driver Licensee Medical Self-Certification Affidavit
25317
THIS FORM MUST BE COMPLETED BY THE COMMERCIAL DRIVER AND RETURNED TO DMV
PART ONE - Commercial Driver’s Name and License Number
Name of Driver
License Number
EXACTLY AS IT APPEARS ON THE COMMERCIAL DRIVER’S LICENSE
PART TWO - Commercial Driver Status Selection
1.)
As a CDL Holder, you must FIRST chose the status that BEST describes you as a commercial driver, Excepted or Non-Excepted.
EXCEPTED Status
NON-EXCEPTED Status
OR
If you transport school children or you are a Federal,
(For Non-Excepted status, choose ONE of the
State, or local government employee, and you are
following below, NA or NI)
exempt from the Federal Motor Carrier Safety
Administration (FMCSA) medical requirements your
status should be listed as Excepted. (For Excepted
status choose ONE of the following below, EA or EI)
2.)
NEXT, check the appropriate box below your selected status that best describes what type of driver you are.
(EA)
(NA)
Excepted Intrastate
Non-Excepted Intrastate
Check here if while using your CDL you stay
Check here if you are under the age of twenty-one
within West Virginia State borders.
(21) or you require a WV Medical Waiver to meet
FMCSA medical standards. Both scenarios require
a “K” restriction on your commercial driver’s license.
OR
The Non-Excepted Intrastate status allows the
commercial driver to travel in state only.
(EI)
Excepted Interstate
You are required to submit a valid DOT Medical
Examiner’s Certificate (DOT card) and copy of Medical
Check here if while using your CDL you cross
Waiver, if applicable.
West Virgina State borders.
OR
(NI)
Non-Excepted Interstate
Check here if you do not meet any of the other listed
categories. The Non-Excepted Interstate status allows
the Commercial driver to travel in-state and out of state.
You are required to submit a valid DOT Medical
Examiner’s Certificate (DOT card).
PART THREE - Commercial Driver Certification and Return Information
Complete and return this form
WV DMV
with ALL additional required
PO Box 17010
(X)
documents (if applicable) to:
Charleston, WV 25317
SIGNATURE OF CDL HOLDER
DATE

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