Commercial Driver Medical & Self Certifying Verification

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STATE OF ALASKA
DIVISION OF MOTOR VEHICLES
413
COMMERCIAL DRIVER MEDICAL & SELF CERTIFYING VERIFICATION
THIS SECTION MUST BE COMPLETED IN FULL BY THE APPLICANT.
MUST BE COMPLETED IN BLACK OR BLUE INK.
FULL
First
Middle
Last
Suffix
LEGAL
NAME:
AK license / permit / ID number, if applicable.
Date of Birth
E-Mail Address
YES
NO
1.
Do you meet all the requirements contained in the federal government regulations shown on the back of this form?
List each requirement you do not meet: (Example: age 19)
2.
Are you required to have a federal or state waiver to meet the medical requirements for a Commercial Driver License?(
)
Insulin, vision or skills performance evaluation certificate
YES
NO
If you answered YES, you must provide a copy of the waiver.
PLEASE CHECK THE APPROPRIATE BOX FOR THE TYPE OF OPERATION THAT APPLIES TO
YOU. SEE THE BACK OF THIS FORM FOR GUIDANCE AND DEFINITIONS:
NON-EXCEPTED INTERSTATE (NI)
A type of operation that does not fall under the excepted types of operation
AND only operates in interstate commerce (see reverse for more information).
(Current medical certificate required.)
NON-EXCEPTED INTRASTATE (NA)
operation
A type of operation that does not fall under the excepted types of
AND only operates in intrastate commerce (see reverse for more information).
(Current medical certificate required.)
EXCEPTED INTERSTATE (EI)
A type of operation that falls under the excepted types of operation
(Medical certificate NOT required.)
AND only operates in interstate commerce (see reverse for more information).
EXCEPTED INTRASTATE (EA)
A type of operation that falls under the excepted types of operation
(Medical certificate NOT required.)
AND only operates in intrastate commerce (see reverse for more information).
IF YOU HAVE SELECTED NON-EXCEPTED INTERSTATE OR NON-EXCEPTED INTRASTATE, YOU MUST
PROVIDE A CURRENT MEDICAL CERTIFICATE TO THE DMV. DMV WILL RETAIN A COPY FOR ITS RECORDS.
YOU ARE STILL REQUIRED TO HAVE A CURRENT MEDICAL CERTIFICATE IN YOUR POSSESSION WHEN
OPERATING A COMMERCIAL MOTOR VEHICLE.
I have personally reviewed the information on this application and certify under penalty of perjury that to the best of my knowledge and belief the
information on this application is true and correct. (NOTE: Making a false statement or omitting a material fact is subject to a maximum penalty of
$10,000 or 1 year imprisonment or both per AS 11.56.210 and AS 28.35.135.)
X____________________________________________________________________________________
Signature of Applicant
Date
INSTRUCTIONS FOR SUBMITTING THIS FORM:
If you are applying for an original, duplicate or renewal of your Commercial Driver License (CDL), please take all required forms to your local DMV.
If your CDL is current, you may submit the form along with any other documents that apply to you (Medical
Examiner’s Certificate, State or Federal Waiver, Skills Performance Evaluation) in the following manner:
Mail to the address listed below;
Scan and email to doa.dmv.ads@alaska.gov;
Deliver to your local DMV Office. A list of office locations and hours can be found on the DMV’s website.
Your DMV record will be updated with your current medical information within 10 calendar days from the date of receipt.
Anchorage Driver Services
1300 W. Benson Blvd, Ste. 100
Anchorage, AK 99503
(Rev.02/29/2016)
Alaska.gov/dmv

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