Cdl Self Certification Form And Attached Medical - Colorado
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1DR 2904 (04/09/12)
COLORADO DEPARTMENT OF REVENUE
1375 SHERMAN STREET
DENVER CO 80261
CDL SELF CERTIFICATION FORM & ATTACHED MEDICAL
Federal Regulation 49 CFR 383.71 requires all CDL holders to have a DOT medical and self certification of commercial
driving on file with their State Driver License Administration (SDLA). Colorado statute and rule (42-2-235 and rule 8 CCR
1507-1) requires that ALL Colorado CDL holders be medically qualified to drive a CMV by the means of a valid DOT medical
or medical waiver.
Please complete this form. Incomplete or illegible forms will be rejected.
Individual’s Name
Date of Birth
Colorado Driver’s LIcense Number
Signature
Date
This completed form can be faxed to 303-205-5709 Attn: CDL Unit or mailed to:
Colorado Department of Revenue
ATTN: CDL Unit Room 154
1881 Pierce St.
Lakewood CO 80214
Please mark the applicable box:
A. Non-excepted Interstate - A person must certify that he or she operates or expects to operate in interstate commerce,
is both subject to and meets the qualification requirements under 49 CFR part 391 and is required to obtain a medical
examiners certificate
B. Excepted Interstate - A person must certify that he or she operates or expects to operate in interstate commerce,
but engages exclusively in transportation or operations excepted under 49 CFR 390.3(f), 391.2, 391.68 or 398.3.
C. Non Excepted Intrastate – A person must certify that he or she operates only in intrastate commerce and therefore
is subject to State driver qualification requirements.
D. Excepted Intrastate – A person must certify that he or she operates in intrastate commerce but engages exclusively
in transportation or operations excepted from all or parts of the State Driver qualification requirements
.
PLEASE ATTACH A COPY OF
THE DOT MEDICAL
CERTIFICATE HERE BEFORE
SENDING TO THE CDL UNIT/DMV
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