Self-Certification For A Commercial Driver'S License
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1STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
DIVISION OF MOTOR VEHICLES
COMMERCIAL DRIVER’S LICENSE OFFICE
600 New London Avenue
Cranston, RI 02920-3024
Phone: 401-462-4368
SELF-CERTIFICATION FOR A COMMERCIAL DRIVER’S LICENSE
Name: ___________________________________________________
R.I. License Number: ___________________
Date of Birth: ___________________
Residence Address: ___________________________________________________________________
NUMBER AND STREET
CITY/TOWN
STATE
ZIP CODE
NOTE: ALL CDL HOLDERS MUST SELF-CERTIFY PRIOR TO JANUARY 31, 2014
You must determine what type of commerce you operate in. You must certify to the Division of Motor
Vehicles (DMV) one (1) of the four (4) types of commerce you operate in as listed below:
(Choose one)
1.
Interstate non-excepted: You are an Interstate non-excepted driver and must meet the Federal
DOT medical card requirements (e.g. – you are “not excepted”).
2.
Interstate excepted: You are an Interstate excepted driver and do not have to meet the Federal
DOT medical card requirements.
3.
Intrastate non-excepted: You are an Intrastate non-excepted driver and are required to meet
the medical requirements for your State.
4.
Intrastate excepted: You are an Intrastate excepted driver and do not have to meet the medical
requirements for your State.
If you are subject to the DOT medical card requirements, please provide a new DOT medical card to
your DMV (located in Cranston) prior to the expiration of the current DOT medical card.
Signature: __________________________________________
Date: ___________________
rev. 12/11
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