Commercial Driver License Medical Self-Certification Form 2014

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MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
445 Minnesota Street
Saint Paul, MN 55101-5175
Phone: (651) 297-5029
Web: dvs.dps.mn.gov
Comm erc ia l Dr i ve r L ic e ns e Me dic al S elf -c e rt ifica tion Form
Instructions:
All commercial driver's license (CDL) holders, Class A, B or C, must complete and submit this self-certification form for initial,
renewal or change in class application. Refer to the Tennessen Warning on the back of this form.
Drivers who check Category 1 or Category 3 below must also submit a current medical examiner's certificate from a certified
medical examiner and any applicable waivers.
All CDL holders with a school bus endorsement MUST submit a current medical examiner's certificate from a certified medical
examiner.
If there is a change in your medical status or interstate/intrastate status you MUSTprovide a new self-certification form.
If you have any questions or concerns, contact Driver and Vehicle Services by phone (651) 297-5029.
Please submit this completed self-certification form and your medical examiner's certificate from a certified medical examiner
and/or medical waiver, if applicable by mail: Driver and Vehicle Services Division, 445 Minnesota Street, Suite 175, St. Paul,
MN 55101-5175, by fax to (651) 297-4447 or in person at any driver exam station or driver license office that accepts
applications. Refer to the
Driver and Vehicle Services Website
for a list of locations.
Driver Information:
Print Name (First, Middle, Last)
Date of Birth (mm/dd/yyyy)
-
-
-
-
Minnesota Driver's License Number:
Please check only one of the following self-certification categories that apply to you:
I certify my commercial operating status is--check only one category box below:
(Checking more than one category box will delay processing this form)
Category 1 - Non-exempt Interstate, subject to 49 CFR part 391
(Current medical examiner's certificate from a certified medical examiner must be submitted).
Category 2 - Exempt Interstate, exempt from medical examination requirements of 49 CFR part 391
Category 3 - Non-exempt Intrastate, subject to state medical examination requirements of Minn. Stat., ch. 221
(Current medical examiner's certificate from a certified medical examiner must be submitted).
Category 4 - Exempt Intrastate, exempt from state medical examination requirements listed in Minn. Stat., ch. 221
Please answer the following two questions:
1. Are you submitting a copy of your medical examiner's certificate from a certified medical examiner?
Yes
No
Yes
No
2. Are you submitting a copy of a medical waiver?
X
Driver's Signature
Date
PS33203-05 (01/14)
- over -

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