Driver Certification For Issuance Of A Commercial Driver'S Permit Or License printable pdf download

Driver Certification For Issuance Of A Commercial Driver'S Permit Or License

MVD–11222

New Mexico Taxation & Revenue Department, Motor Vehicle Division

REV. 06/12

Driver Certification for Issuance of a

Commercial Driver’s Permit or License

Any falsification of required information may result in the immediate cancellation of the

Applicant’s CDL and any CDL Endorsements and may result in prosecution.

Applicant Information

Applicant’s Full Legal Name (Last, First, Middle)

Social Security Number

Driver’s License Number

Applicant Certification



I certify that the Commercial Motor Vehicle in which I will take my skills tests is representative of the

type of motor vehicle I will operate or expect to operate, or representative of the Endorsement for

which I have applied.



I certify that I am not subject to any license disqualification, suspension, revocation, or cancellation

under state law and that I do not have a non-commercial or commercial driver license from more than

one state or jurisdiction.



I certify that my current CDL driver category is as indicated below (check the one that applies).



NI – Non-Excepted Interstate

NA – Non-Excepted Intrastate

I am an interstate driver, and I am required to meet

I am an intrastate driver, and I am required to meet the

the Federal DOT medical card requirements.

medical requirements of the State of New Mexico.



EI – Excepted Interstate

EA – Excepted Intrastate

I am an interstate driver, and I do not have to meet the

I am an intrastate driver, and I do not have to meet the

Federal DOT medical card requirements.

medical requirements of the State of New Mexico.



I certify that within the past ten (10) years, I have been previously licensed in the following state(s)

to drive any type of motor vehicle. List states, from the most current to the least current.

10.

Applicant’s Signature

Date

Driver Certification For Issuance Of A Commercial Driver'S Permit Or License