Commercial Driver License Intrastate Medical Waiver Application
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Commercial Driver License
Intrastate Medical Waiver Application
Use this form to apply for an intrastate medical waiver if you have or are applying for a commercial driver license (CDL)
and do not meet the minimum federal medical/vision standards. This form is not for drivers that do not have a CDL. For
questions about your drive record we suggest you check your driving status online at Send this form and
a complete copy (the DOT medical card is not sufficient) of your most current Medical Examination Report to:
CDL Medical Unit
Department of Licensing
PO Box 9030
Olympia, WA 98507-9030
Email: CDLMED@dol.wa.gov (only CDL medical forms are accepted at this email address)
Fax (360) 570-4915
Allow 7-10 business days for processing. Incomplete applications will not be processed.
PRINT or TYPE Driver name (Last, First, Middle initial)
Driver license number
Date of birth
(Area code) Telephone number
Describe the disqualifying medical condition(s) for this waiver
Certification
I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
I understand that false statements on this application may result in cancellation of my commercial driving privilege.
X
When completed, please print this out and sign here.
Signature
Date
Physician use only – This section must be completed by a licensed medical doctor (MD), a doctor of osteopathy (DO),
a board certified physiatrist (doctor of physical medicine), or an orthopedic surgeon. An optometrist or an ophthalmologist
signature is acceptable for vision impairments and a certified nurse practitioner can sign only for monocular vision, color
blindness, or hearing impairments.
PRINT or TYPE Medical examiner name
Office street address
City
State
ZIP code
(Area code) Telephone number
Professional license number
Certification
The above driver’s medical condition is not likely to interfere with the ability to safely operate a commercial motor vehicle
and is likely to remain stable for:
the next two years
other
Not more than two years
X
Medical examiner: Please sign here.
Medical examiner signature
Date
Title
DLE-520-066 (R/1/14)WA
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