Michigan Department Of State Cdl Self-Certification Form
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1Michigan Department of State
Clear Form
CDL Self‐Certification Form
Full Name: (Please Print)
Driver’s License Number:
Date of Birth:
CERTIFYING TO THE TYPE OF COMMERCIAL MOTOR VEHICLE (CMV) DRIVING I WILL DO AS REQUIRED IN 49 CFR PARTS 383 AND
391 (Choose only ONE of the following types.)
I will operate or expect to operate a CMV in the following manner:
Non-excepted interstate - I will operate a CMV outside of Michigan. I must also provide my medical certificate (DOT medical card).
Excepted interstate - I will operate a CMV outside of Michigan solely for an excepted purpose and am not legally required to have a
medical certificate (DOT medical card).
Non-excepted intrastate - I will operate a CMV solely within Michigan (intrastate commerce) and am legally required to have a medical
certificate (DOT medical card).
Excepted intrastate - I will operate a CMV solely within Michigan for an excepted purpose and am not legally required to have a medical
certificate (DOT medical card).
I certify the information disclosed on this form is true. I understand making a false statement when applying for a driver’s license is a crime.
Signature:
Date:
DRIVING TYPES
Non-excepted interstate. Operates a commercial motor vehicle outside of Michigan and must provide a legible copy to the Secretary of
State of one of the following medical certification documents:
A completed Medical Examiner’s Certificate signed by a medical professional. You must also keep this document with you until
January 30, 2014 when operating a commercial motor vehicle.
An FMCSA Skills Performance Evaluation document and/or an FMCSA document listed in 49 CFR 381 Subpart C, authorizing
operation of a CMV. This document must be in your possession when operating a CMV.
Note: Operation of a CMV within state lines is considered interstate commerce if the origin and/or destination of the load crosses state
lines.
Excepted interstate. Operates a CMV outside of Michigan only for excepted purposes listed below.
Note: Operation of a CMV within state lines is considered interstate commerce if the origin and/or destination of the load crosses state
lines.
Excepted Interstate Purposes:
49 CFR §390.3(f): State and federal transportation, occasional transportation of personal property not for compensation,
transportation of human corpses or sick/injured persons, fire trucks and rescue vehicles, commercial vehicles designed or used to
transport between 9 and 15 passengers (including the driver), transportation of propane winter heating fuel.
49 CFR §391.2: Farm custom operations, apiarian industries (beekeepers seasonally transporting bees), certain farm vehicle drivers.
49 CFR §391.68: Private motor carrier of passengers (nonbusiness).
49 CFR §398.3: Driver of migrant workers.
Non-excepted intrastate. Operates a CMV only within Michigan (intrastate commerce). Your medical certification and/or a Motor Carrier
Division Medical Waiver does not need to be provided to the Department of State. However, the medical certification and/or a Motor
Carrier Division Medical Waiver must be in your possession when operating a CMV.
Excepted intrastate. Operates a CMV only within Michigan (intrastate commerce) only for an excepted purpose listed below.
Excepted Intrastate Purpose:
MCL 480.15(2)-(5): A self-propelled implement of husbandry or an implement of husbandry being drawn by a farm tractor or another
implement of husbandry; public utility, telephone, and cable television company service vehicles that do not meet the definition of a
CMV in 49 CFR part 383; or a public utility service vehicle used in cases of emergency.
Complete and return this form and any related documents online, by fax or mail or in person at any Secretary of State office.
Fax Number: (517) 636‐4359
Website: Mailing Address: Michigan Department of State
CDL Help Desk
7064 Crowner Drive
CDL Self‐Cert Web form (Rev. 10/13)
Lansing, MI 48918
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