Cdl Self Certification
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OFFICE OF THE SECRETARY OF STATE
JESSE WHITE • Secretary of State
Name: ____________________________________________________________________________
Driver’s License Number: ____________________________________________________________
Date: _____________________________________________________________________________
Self-certify by marking one of the boxes below.
n n
Non-excepted interstate (NI) – Operates or expects to operate in interstate commerce and is
both subject to and meets the requirements under 49 CFR part 391.
n n
Excepted interstate (EI) – Operates or expects to operate in interstate commerce, but engages
exclusively in transportation or operations excepted (school bus operations, federal and state
employees, transportation of personal property, transportation of human corpses or sick and
injured persons, operation of fire trucks and rescue vehicles while involved in emergency and
related operations).
Non-excepted intrastate (NA) – Operates only in intrastate commerce and therefore is subject to
State driver qualification requirements. To select this category you must visit a CDL facility
to have a “K” restriction placed on your CDL license.
Excepted intrastate (EA) – Operates in intrastate commerce, but engages exclusively in transporta-
tion or operation excepted from all or parts of the state driver qualification requirements. To
select this category you must visit a CDL facility to have a “K” restriction placed on your
CDL license.
Disclosure Statement
Under penalties of perjury, I swear or affirm that all information submitted by me regarding this
medical certificate is true and accurate.
____________________________________
________________________________________
Driver’s Signature
Date
2701 South Dirksen Parkway
Springfield, Illinois 62723
Printed by authority of the State of Illinois. December 2015 - 1 - DSD A 299
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