Mve-64c - Cdl Medical Self-Certification Form

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State of Maine
Secretary of State
Bureau of Motor Vehicles
CDL Compliance Unit
CDL Medical Self-Certification Form
Name of Driver:
ME Lic #:
(Please print)
I certify that I meet the following medical requirements contained in Section 391 of the
Federal Motor Carrier Safety Regulations (FMCSR).
For more information regarding medical
certification requirements visit
Please check only one of the following Self-Certification driving types that apply to you.
Non-excepted Interstate:
I operate or expect to operate in interstate commerce. I am subject to and meet
the medical qualification requirements in FMCSR section 391 and required to obtain a medical examiner’s
certificate. A valid medical certificate must accompany this form.
Excepted Interstate:
I operate or expect to operate in interstate commerce, but engage exclusively in
transportation or operations excepted from FMCSR section 391 and therefore not required to obtain a medical
examiner’s certificate. Examples include: school bus operations, fire trucks & rescue vehicles, transportation by
Federal or State government, transportation of human corpses or sick and injured persons. For a complete list of
operations excepted see 49 CFR 390.3(f), 391.2, 391.68 or 398.3.
*Non-excepted Intrastate
: I certify that I operate only in intrastate commerce and am subject to State
driver qualification requirements. A valid medical certificate must accompany this form. There are no
exemptions for motor carriers, vehicles, or drivers transporting hazardous materials of a type or quantity that
requires the vehicle to be marked or placarded in accordance with 49 CFR, Subchapter C, Pt. 172. Example: Oil
Truck Drivers.
*Excepted Intrastate:
I certify that I operate in intrastate commerce but engage exclusively in
transportation or operations excepted from all or parts of the State driver qualification requirements. Example:
Drivers that operate less than 100 air miles from their regular place of business.
Signature:
Date:
Telephone Number:
Please submit the form in one of the following ways:
 Mail to:
Bureau of Motor Vehicles
CDL Compliance Unit
29 State House Station
Augusta, ME 04333-0029
 Fax:
(207) 624-9339
 E-mail:
cdlcompliance.BMV@maine.gov
(must be scanned as a word document or PDF)
 Give to Customer Service Representative in any
Branch Office
or mobile unit location. For a
complete list of locations visit:
If you need further assistance, call (207) 624-9000 ext. 52126.
MVE – 64C Revised 7/15

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