Driving Certification Maryland Motor Vehicle Administration Form (Color) printable pdf download

Driving Certification Maryland Motor Vehicle Administration Form (Color)

Maryland Motor Vehicle Administration

6601 Ritchie Highway, N.E.

Room 145, Attn: CDL Med Cert

Glen Burnie, MD 21062

Driving Certification for Maryland Commercial Driver’s License Holders

PLEASE READ AND COMPLETE.

Applicant Information (Please Print):

*Indicates a required field

Driver License Number

Date of Birth (Month/Day/Year)

Current Medical Certificate Expiration

Date (Month/Day/Year)

Middle Name

Suffix

First Name

Last Name

** You must provide either a

Contact Phone Number **

Contact Phone Number

Address

Email Address **

Select one of the following four options:

Certification:

I am qualified to operate a commercial motor vehicle

Interstate and have a valid medical examiner’s certificate. (NI)

Intrastate (within MD) OR I am under the age of 21 OR I have an approved MVA CDL Medical Waiver. (NA)

Interstate and am exempt from obtaining a medical examiner’s certificate. (EI)

Intrast

Intrastate (within MD) and meet all applicable MD State requirements. (EA)

I certify, under penalty of perjury that the statements made by me on this application are true

and correct to the best of my knowledge, information and belief.

__________________________________

_________________________

Signature

Date

Revised 06May2013

Driving Certification Maryland Motor Vehicle Administration Form (Color)