Oklahoma Commercial Driver License Medical Self-Certification Affidavit printable pdf download

Oklahoma Commercial Driver License Medical Self-Certification Affidavit

Oklahoma Commercial Driver License

Medical Self-Certification Affidavit

Name of Driver: _________________________________

Oklahoma Driver’s License Number: _________________________ Phone #: _____________________

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 only the first self-certification box below must submit a copy of their medical

certificate, however, all Class A, B, or C drivers must submit this affidavit.

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

I certify my commercial transportation is:

1. Non-excepted Interstate (NI). I operate or expect to operate in Interstate commerce and

subject to 49 CFR part 39. (Medical certificate and affidavit must be submitted).

2. Excepted Interstate (EI). I operate or expect to operate in Interstate commerce, but operation

exclusively in transportation or operations excepted under 49 CFR 390.3 (f), 391.2, 391.68, or

393.3. (Only this affidavit must be submitted).

3. Non-excepted Intrastate (NA). I operate ONLY in intrastate commerce and subject to state

driver qualification requirements. (Only the affidavit must be submitted).

4. Excepted Intrastate (EA). I operate in intrastate commerce, but operating exclusively in

transportation or operations excepted from all or part of the state driver qualification

requirements. (Only the affidavit must be submitted).

____________________________________

_______________________

Driver's Signature

Date

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

Oklahoma Department of Public Safety

CDL Administration

PO Box 11415

Oklahoma City, Ok 73136-0415

mec@dps.ok.gov

Fax to 405-419-2196

Oklahoma Commercial Driver License Medical Self-Certification Affidavit