Form Sf-1438 - Tennessee Department Of Safety Supplemental - Application For Commercial Driver License Template Page 2
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2TENNESSEE DEPARTMENT OF SAFETY
SUPPLEMENTAL APPLICATION FOR COMMERCIAL DRIVER LICENSE
DATE ________/________/20 _____
APPLICATION NUMBER
Original
Duplicate
Renewal
Last Name
First Name
Middle Initial
Suffix
Tennessee Driver License Number
Social Security Number
DATE OF BIRTH
/
/
Month/Day/Year
DAYTIME PHONE NUMBER TO REACH YOU
CELL PHONE
Initial Below
IMPORTANT - All Applicants must certify to Item 1, 2, 3 or 4, whichever is applicable.
1. __________ I certify that I operate or expect to operate in interstate commerce, and meet the qualification requirements under Title 49, Code
of Federal Regulations, (“CFR”) Part 391, operating in interstate commerce and I am required to obtain a medical examiner’s certificate by
§391.45 of this chapter;
2. __________ I certify that I operate or expect to operate in interstate commerce, but engage 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 therefore
I am not required to obtain a medical examiner’s certificate by 49 CFR 391.45 of this chapter;
3. __________ I certify that I operate or expect to operate only in intrastate commerce, and I am subject to the State of Tennessee driver
qualification requirements for operating a commercial vehicle.
4. __________ I certify that I operate in intrastate commerce, but engage exclusively in transportation or operations excepted from all or parts
of the State of Tennessee’s driver qualification requirements for operating a commercial vehicle per Tenn. Comp. R. & Regs. 1340-1-13 (2008).
I further certify that I am not required to have the Passenger, School Bus, or Hazardous Materials endorsement.
**All applicants must complete items 5 and 6. Only complete item 7 if a skills test is required.**
5. __________ I certify that I am not subject to disqualification under Title 49, CFR, Part 383.51 or any license suspension, revocation or
cancellation under State Law.
6. __________ I certify that I do not have a driver’s license from more than one state or jurisdiction.
7. __________ I certify that the vehicle in which I will take the commercial motor vehicle skills test is representative of the type and size of
motor vehicle I operate or expect to operate.
8. __________ I certify that during the past 10 years I have not had a license in any state other than Tennessee. (If you have had a license in
another state or cannot certify this statement, you must complete the 10 year licensing history form (Page2) that is attached).
I certify that the information provided in this application is correct and true to the best of my knowledge. I understand that supplying
false information may result in the suspension of my driving privilege and may subject me to prosecution under state law (see TCA §
55-50-601 et seq). My signature below represents consent to release my driving record information. I also understand the required
application fee is non-refundable.
__________________________________________________
____________________________
Applicant Signature
Date
DEPARTMENTAL USE ONLY - DO NOT WRITE BELOW THIS LINE
DOT Medical Card Expiration Date
CDLIS
CDL
Pass
Fail
Examiner
Pass
Fail
RESULTS
GK
P
F
P-Passenger
P
F
Air Brakes
P
F
S-School Bus
P
F
Verifying
Comb
P
F
Skills
Pre-Trip
P
F
N-Tanker
P
F
Basic Ctrl
P
F
Unlock
T-Doubles
P
F
Road Test
P
F
H-HazMat
P
F
If 3rd party:
Certificate #:
Class license
to be issued:
A
B
C
S/CDL
PA
PB
PC
SF-1438
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