Medical Certification Of Driver Type For Commercial Driver License
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1CDL-MED-1
(Rev. 11/13)
State of North Carolina
North Carolina Department of Transportation
Division of Motor Vehicles
M
C
EDICAL
ERTIFICATION
of Driver Type
F
C
D
L
OR
OMMERCIAL
RIVER
ICENSE
Name
(First)
( Middle)
(Last )
(Suffix)
North Carolina License Number:
Social Security Number
Date of Birth:
CHECK THE APPROPRIATE BOX FOR THE TYPE OF OPERATION THAT APPLIES TO YOU
ONLY ONE BOX MAY BE CHECKED
NON-EXCEPTED INTERSTATE: operates or expects to operate in interstate commerce, is
both subject to
and meets the qualification requirements under 49 CFR part 391, and is required to obtain a medical examiner’s
certificate by 391.45.
(Required to have a DOT medical card/certificate)
EXCEPTED INTERSTATE: operates or expects to operate in interstate commerce, but engages exclusively in
transportation or operations excepted under 49 CFR 390.3(f), 391.2, 391.68 or 398.3 from all or parts of the
qualification requirements of 49 CFR part 391, and is, therefore, not required to obtain a medical examiner’s
certificate.
(See Medical Certification Requirements FAQ Sheet)
NON-EXCEPTED INTRASTATE: operates only in intrastate commerce and, therefore, is subject to State driver
requirements.
(Required to have a DOT medical card/certificate and license has restriction “K")
EXCEPTED INTRASTATE: operates in intrastate commerce but, engages exclusively in transportation or
operations excepted from all or parts of the State driver qualification requirements
(License has restriction “K")
I certify under penalty of perjury that all statements above are true and correct.
Signature:
Date:
1) Scan the documents and then email them to:
CDLmedical@ncdot.gov
2) Mail this form and copies of medical card/certificate to:
NCDMV
CDL Medical Certification Unit
3126 Mail Service Center
Raleigh, NC 27699-3126
3) Fax this form and medical documents to the CDL Med. Cert Unit. Fax number is (919) 861-3915
4) Deliver this form and medical documents to your local NCDMV office. A list of office locations and
hours can be found on our website
Please contact the CDL Medical Certification Unit at (919) 861-3599 if you have any questions regarding this
form.
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