Commercial Driver License Medical Self-Certification Statement printable pdf download

Commercial Driver Licensee

Medical Self-Certification Statement (

)

Please Print

Name of Driver: _____________________________________

South Dakota Driver License Number: ___________________

The information on this form is also included on the driver license application form. This form is only required if

you are reporting your “medical self-certification” and do not need a driver license issued (or if you are

reporting your medical status for the first time or have had a change of medical certification status).

Are you submitting a copy of your medical certificate?

YES

(Please circle yes or no)

Note: Only Class A, B, or C drivers that check the first and fourth self-certification box below must submit a

copy of their medical certificate; however all Class A, B, or C drivers must submit this statement.

Please check only one of the following Self-Certification categories that apply to you.

I certify my commercial transportation is:

Non-excepted Interstate. Interstate and subject to 49 CFR part 391. (Medical certificate and this

statement must be submitted).

Excepted Interstate. Interstate, but operating exclusively in transportation or operations excepted under

49 CFR 390.3 (f), 391.2, 391.68, or 398.3. (Only this statement must be submitted).

Excepted Intrastate. Intrastate, but operating exclusively in transportation or operations excepted from all

or part of the State driver qualification requirements. (Only this statement must be submitted).

Non-excepted Intrastate. Intrastate and subject to State driver qualification requirements (school bus

drivers - medical certificate and this statement must be submitted).

Please Note: If you have a school bus endorsement but no longer have a medical certificate you must be

issued a new commercial driver license without the school bus endorsement. To do this, a completed

application, required documentation, and applicable fee must be presented at a driver license exam station.

_________________________________________

__________________

Driver’s Signature

Date

I declare and affirm under the penalties of perjury (2 years imprisonment and $4,000 fine) that this statement

has been examined by me, and to the best of my knowledge and belief, is in all things true and correct. Any

false statement or concealment of any material facts subjects any license to immediate cancellation.

Please mail, fax, or email the medical certificate (if applicable) and this Self-Certification Statement to:

Driver Licensing

118 West Capitol Avenue

Pierre, SD 57501

Fax to 605-773-3018

Email to

DPSCDLMedCert@state.sd.us

04-03-2014

Commercial Driver License Medical Self-Certification Statement