Form Dpsmv 2211 - Supplemental Form For Cdl Application printable pdf download

LOUISIANA DEPARTMENT OF PUBLIC SAFETY & CORRECTIONS

OFFICE OF MOTOR VEHICLES

SUPPLEMENTAL FORM FOR CDL APPLICATION

Full Name

(last)

(first)

(middle)

Mailing Address

City/State/Zip

(DL#/State issued)

Date of Birth

SSN:

All CDL applicants, answer the following questions:

Circle one

1) Have you ever held a driver license in this or any other state within the

Y / N

past 10 years? If yes, list the state/s?

2) Do you have a driver’s license from more than one State or Jurisdiction?

Y / N

3) Are your driving privileges currently or pending suspension, revocation,

or cancellation under State law or disqualification under 49 CFR 383.51?

Y / N

4) Do you meet the qualification requirements of 49 CFR 391?

Y / N

5) You must self-certify as one of the following four types of commercial driver’s:

Interstate non-excepted: You are an Interstate non-excepted driver and must meet

the Federal DOT medical card requirements. In addition, La. R.S. 32:403.4 requires all

commercial drivers to have a valid physical examination form and medical examiner’s

certificate.

Interstate excepted: You are an Interstate excepted driver and do not have to meet

the Federal DOT medical card requirements, however, La R.S. 32:403.4 requires all

commercial drivers to have a valid physical examination form and medical examiner’s

certificate.

Intrastate non-excepted: You are an Intrastate non-excepted driver and are

required to meet the Federal DOT medical card requirements. In addition, La. R.S.

32:403.4 requires all commercial drivers to have a valid physical examination form

and medical examiner’s

certificate.

Intrastate excepted: You are an Intrastate excepted driver and do not have to meet

the Federal DOT medical card requirements, however, La R.S. 32:403.4 requires all

commercial drivers to have a valid physical examination form and medical examiner’s

certificate.

I hereby certify that the motor vehicle in which I take/took the driving skills test is representative of the type of

motor vehicle that I operate or expect to operate.

By my signature affixed below, I certify under penalty of law, that all statements on this application are true and

correct.

Applicants signature

Date

MVCA signature

Date

DPSMV 2211 (R 5/14)

Form Dpsmv 2211 - Supplemental Form For Cdl Application

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