Cdl Medical Self-Certification Affidavit printable pdf download

Cdl Medical Self-Certification Affidavit

Commercial Driver Licensee

Medical Self-Certification Affidavit (Please Print)

Name of Driver:_______________________________________________

Mississippi Driver License Number :_______________________________

Only Class A,B or C drivers that check the first and third self-certification box below must submit a copy

of their medical certificate; however all Class A, B, C drivers must submit this affidavit.

Please check only one of the following Self-Certification categories that apply to you.

I certify my commercial transportation is:

___ Interstate Non- Excepted – Interstate, and subject to 49 CFR part 391 (Medical certificate and

affidavit must be submitted). Ex. Transporting interstate commerce

___ Interstate Excepted- Interstate, but operating exclusively in transportation or operations excepted

under 49 CFR 390.3 (f) 391.2, 391.68, or 393.3 (Only the affidavit must be submitted). Ex. Beekeeper,

custom harvesting , school bus operations

___ Intrastate Non –Excepted -Intrastate and subject to State driver qualification requirements (Medical

certificate and affidavit must be submitted). All class A,B,C drivers must have a Medical certificate

F RESTRICITON MUST BE ADDED

___Intrastate Excepted- Intrastate, but operating exclusively in transportation or operations excepted

from all or part of the State driver qualification requirements. (Only the affidavit must be submitted).

Ex. Insulin Dependent In State School Bus Drivers (F RESTRICTION MUST BE ADDED)

_______________________________________

_______________________

Driver’s Signature

Date

CDL Affidavit 29 (1-19-12)

Cdl Medical Self-Certification Affidavit