Massdot Cdl Self-Certification Form

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CDL SELF-CERTIFICATION FORM
As a Commercial Driver’s License (CDL) or permit holder, you are federally required to inform the Registry of Motor Vehicles (RMV) of
the type of commerce in which you operate (interstate or intrastate), and whether or not you are required to hold a US DOT Medical
Examiner’s Certificate (also referred to as a medical certificate or medical card). If you are an NI or NA categorized driver, you will
need to re-certify, using this same form, prior to each expiration of your medical certificate. Depending on the validity period of your
certificate, you will most likely have to re-certify every 1-2 years. Failure to complete your initial self-certification, or to re-certify by
your self-certification expiration date thereafter, will result in the downgrade of your CDL to a Class D license. EI and EA categorized
drivers will be required to re-certify every five years at the time of license renewal. A driver may also need to re-certify prior to an
expiration date if the type of driving that is conducted has changed or if the driver has been issued a new medical certificate.
(Please either print clearly or type)
COMMERCIAL DRIVER INFORMATION
DRIVER NAME
(last)
(first)
(middle)
BIRTHDATE (mm/dd/yyyy)
ADDRESS (street)
(city)
(state)
(zip code)
LICENSE/PERMIT NUMBER
DAYTIME TELEPHONE NUMBER
EMAIL ADDRESS
Please select only one of the following self-certification categories. See page two (2) of this form for category definitions.
I certify my commercial driving is:
Non-Excepted Interstate (NI)* (copy of medical certificate required) - I engage in Interstate commerce and must
meet the federal DOT medical certificate requirements
Excepted Interstate (EI) - I engage in Interstate commerce and do not have to meet the DOT medical certificate
requirements
Non-Excepted Intrastate (NA)* (copy of medical certificate required) - I engage in Intrastate commerce and
must meet state driver qualification requirements
Excepted Intrastate (EA) - I engage in Intrastate commerce and do not have to meet the DOT medical certificate
requirements
*If you selected the NI or NA category and do not have a W restriction on your license, you must fill out the medical
If you have a federal medical variance, a state waiver, or a Skill Performance Evaluation Certificate (SPE), which is indicated
certificate portion of this form on page two (2), and provide a copy of your medical certificate.
on your medical certificate, you must also provide a copy of this documentation.
You should self-certify at the highest standard for which you qualify so as not to limit work opportunities. Non-excepted
Interstate (NI) is the broadest category and the one you should select if you meet the criteria, even if you currently do not
consider yourself an interstate driver.
I hereby certify under the penalties of perjury that the information I provided in this CDL Self-Certification Form is true and
complete.
Signature of Driver
Date
Customers who wish to obtain, or who currently hold, a Commercial Driver’s License (CDL) that is being renewed, upgraded,
or transferred from another state, will be required to self-certify at that time if they do not have a current medical certificate
on file with the RMV. This CDL Self-Certification Form and a copy of the medical certificate, if applicable, must be presented
at the time of the transaction.
The easiest and quickest way to complete this form and provide your medical certificate is through our website,
your medical certificate as part of the transaction. You may also submit this form by mail or in person at an RMV branch.
Go to the “Online Services” section and look under “Other”. You will be required to upload
Mail forms to:
Submit forms in person to:
MassDOT, RMV Division, Driver Licensing
Any RMV branch office. Locations can be found by visiting
PO Box 55889
Boston, MA 02205
RMV Override Request – I understand the override that was explained to me by the RMV and I authorize the RMV to
process it.
Customer’s Signature:
Over
T21893-0215

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