Self-Certification Affidavit Template

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SELF-CERTIFICATION AFFIDAVIT
(PLEASE PRINT)
Name of CDL Driver or Applicant _____________________________________________________
Arkansas Driver’s License Number: ____________________________________________________
Are you submitting a copy of your medical certificate at this time?
YES
NO
Please check only one of the following Self -Certification categories that apply to you.
Type 1 – (NI) Non-excepted interstate – Federal Medical Card is required.
- Engaged in interstate commerce.
- Includes Federal Skills Performance Evaluation (SPE), diabetes and vision
variances.
Type 2 – (EI) Excepted interstate – No Federal Medical Card is required.
- Engaged in interstate commerce and operating under one of the following
exceptions:
a. All School bus operations;
b. Transportation performed by any political subdivision;
c. Transportation of human corpses or sick and injured persons;
d. Operation of fire trucks and rescue vehicles while involved in emergency
and related operations;
e. Operation of vehicles designed or used to transport between 9 & 15
passengers not for direct compensation;
f. Transportation of propane winter heating fuel or responding to a pipeline
emergency;
g. Farm custom operation: custom-harvesting operations, transporting farm
machinery, supplies, or both, to or from a farm for custom-harvesting
operations on a farm; or transport custom harvested crops to storage or
market;
h. Operation of a commercial motor vehicle controlled and operated by a
beekeeper engaged in the seasonal transportation of bees;
i. Operation of private motor carrier of passengers (non-business);
j. Occasional transportation of personal property not for compensation or
commercial enterprise;
Type 3 – (NA) Non-excepted intrastate – Federal Medical Card is required.
- Engaged in intrastate commerce.
Type 4 – (EA) Excepted intrastate– No Federal Medical Card is required.
- Engaged in intrastate commerce and subject to an exception. Includes all
exceptions from Type 2.
I hereby certify that the category checked above indicates the type of operation I am engaged in
as a CDL driver
          
 
 
 
Signature 
 
 
 
 
 
     

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