Form Dl-11cd - Self-Certification Form
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2DL-11CD (12-15)
SELF-CERTIFICATION FORM
PLEASE READ IMPORTANT INFORMATION ON THE REVERSE SIDE.
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CHECK APPLICABLE BOX
INITIAL SELF CERTIFICATION
CHANGE SELF CERTIFICATION PREVIOUSLY REPORTED
DRIVER INFORMATION
DRIVER’S LICENSE NUMBER
LAST NAME(S)
JR/ETC
FIRST NAME
MIDDLE NAME
TELEPHONE NUMBER (8:00 a.m. to 4:30 p.m.)
DATE OF BIRTH
E-MAIL ADDRESS (if applicable)
MONTH
DAY
YEAR
If you are not currently working as a commercial driver but would like to keep your CDL, you must submit the below
certification. If you select either the “EA” or “EI” box, you will be able to keep your CDL without submitting a current
medical card. If/When you return to driving a commercial vehicle and you need to carry a medical card, you must
resubmit a DL-11CD, Self-Certification Form, along with a copy of your valid medical card. NOTE: You must be at
least 21 years of age or older to operate a commercial vehicle in non-excepted interstate transportation. A “K”
restriction will be added to your license for any intra-state driving type.
Please check only one of the following Self-Certification driving types that apply to you.
I certify that I drive or expect to drive a commercial vehicle in:
NI
I drive a commercial vehicle both in and outside the boundaries of Pennsylvania, and I currently carry a
Medical Examiner’s Certificate (DOT PHYSICAL CARD).
•
Please enlarge your Medical Examiner’s Certificate to 5 inches by 7 inches and make sure that all of
the health care provider information is complete and legible.
NA I drive a commercial vehicle only within the boundaries of Pennsylvania, and I currently carry a Medical
Examiner’s Certificate (DOT PHYSICAL CARD).
•
Please enlarge your Medical Examiner’s Certificate to 5 inches by 7 inches and make sure that all of
the health care provider information is complete and legible.
EI
I drive a commercial vehicle both in and outside the boundaries of Pennsylvania, and I DO NOT carry a
Medical Examiner’s Certificate.
EA I drive a commercial vehicle only within the boundaries of Pennsylvania, and I DO NOT carry a Medical
Examiner’s Certificate.
ARE YOU SUBMITTING A COPY OF YOUR MEDICAL CERTIFICATE?
YES
NO
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To ensure the prompt processing of your Medical Examiner’s Certificate as required by the Federal Motor
Carrier Safety Regulations, when you copy your wallet card please enlarge the copy to 5 inches by 7 inches
and make sure that all of the health care provider information is complete and legible. These steps will
ensure your information is added to our system correctly and reduce the chance of the information being
returned to you for clarification.
I certify under penalty of law that all commercial certifications and information contained herein are true
and correct.
X
SIGN
HERE
(SIGNATURE IN INK)
DATE
Please mail the Self-Certification form and medical certificate (if applicable) to:
Bureau of Driver Licensing • P.O.Box 69008 • Harrisburg, PA 17106-9008
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