CDL SELF-CERTIFICATION FORM - Registry of Motor Vehicles

CDL SELF-CERTIFICATION FORM
As a Commercial Driver’s License (CDL) or permit holder, you are federally required to inform the Registry of Motor Vehicles (RMV) of
the type of commerce in which you operate (interstate or intrastate), and whether or not you are required to hold a US DOT Medical
Examiner’s Certificate (also referred to as a medical certificate or medical card). If you are an NI or NA categorized driver, you will
need to re-certify, using this same form, prior to each expiration of your medical certificate. Depending on the validity period of your
certificate, you will most likely have to re-certify every 1-2 years. Failure to complete your initial self-certification, or to re-certify by
your self-certification expiration date thereafter, will result in the downgrade of your CDL to a Class D license. EI and EA categorized
drivers will be required to re-certify every five years at the time of license renewal. A driver may also need to re-certify prior to an
expiration date if the type of driving that is conducted has changed or if the driver has been issued a new medical certificate.
COMMERCIAL DRIVER INFORMATION (Please either print clearly or type)
DRIVER NAME
ADDRESS (street)
(last)
(first)
LICENSE/PERMIT NUMBER
(city)
(middle)
(state)
DAYTIME TELEPHONE NUMBER
BIRTHDATE (mm/dd/yyyy)
(zip code)
EMAIL ADDRESS
Please select only one of the following self-certification categories. See page two (2) of this form for category definitions.
I certify my commercial driving is:
Non-Excepted Interstate (NI)* (copy of medical certificate required) - I engage in Interstate commerce and must
meet the federal DOT medical certificate requirements
Excepted Interstate (EI) - I engage in Interstate commerce and do not have to meet the DOT medical certificate
requirements
Non-Excepted Intrastate (NA)* (copy of medical certificate required) - I engage in Intrastate commerce and
must meet state driver qualification requirements
Excepted Intrastate (EA) - I engage in Intrastate commerce and do not have to meet the DOT medical certificate
requirements
*If you selected the NI or NA category and do not have a W restriction on your license, you must fill out the medical
certificate portion of this form on page two (2), and provide a copy of your medical certificate.
If you have a federal medical variance, a state waiver, or a Skill Performance Evaluation Certificate (SPE), which is indicated
on your medical certificate, you must also provide a copy of this documentation.
You should self-certify at the highest standard for which you qualify so as not to limit work opportunities. Non-excepted
Interstate (NI) is the broadest category and the one you should select if you meet the criteria, even if you currently do not
consider yourself an interstate driver.
I hereby certify under the penalties of perjury that the information I provided in this CDL Self-Certification Form is true and
complete.
Signature of Driver
Date
Customers who wish to obtain, or who currently hold, a Commercial Driver’s License (CDL) that is being renewed, upgraded,
or transferred from another state, will be required to self-certify at that time if they do not have a current medical certificate
on file with the RMV. This CDL Self-Certification Form and a copy of the medical certificate, if applicable, must be presented
at the time of the transaction.
The easiest and quickest way to complete this form and provide your medical certificate is through our website,
www.massrmv.com. Go to the “Online Services” section and look under “Other”. You will be required to upload
your medical certificate as part of the transaction. You may also submit this form by mail or in person at an RMV branch.
Mail forms to:
MassDOT, RMV Division, Driver Licensing
PO Box 55889
Boston, MA 02205
Submit forms in person to:
Any RMV branch office. Locations can be found by visiting
www.massrmv.com
RMV Override Request – I understand the override that was explained to me by the RMV and I authorize the RMV to
process it.
Customer’s Signature:
Over
T21893-0215
COMMERCIAL DRIVER INFORMATION (Please either print clearly or type)
DRIVER NAME
(last)
(first)
Medical Examiner’s Certificate Information
(middle)
BIRTHDATE (mm/dd/yyyy)
Please clearly enter the information from your medical certificate in the fields below. If you are required to hold a medical
certificate, you will need to provide the RMV with a copy as part of your self-certification. Filling out the information below
assists us with data processing, but does not replace the requirement to also provide a copy.
1.
Wearing corrective lenses
4.
Driving within an exempt intracity zone (49 CFR 391.62)
3.
Accompanied by a waiver (variance)
exemption
6.
Qualified by operation of 49 CFR 391.64
2.
Wearing hearing aid
5.
Accompanied by a Skill Performance Evaluation
Certificate (SPE)
Condition #6 only applies to a very limited number of drivers who fall under a federal grandfather clause that limits them to
a one year medical certificate. If condition #6 is selected on your medical certificate and you do not fall under the
grandfather clause, condition #6 was most likely chosen by the medical examiner in error. You should return to the medical
examiner to request a revised medical certificate.
Telephone #
Medical Examiner’s Name
Specialty Code (MD, DO, PA, CH, AN, or Other)
Medical Examiner’s National Registry # (new requirement)
If #3 is checked: Exemption Effective Date
If #5 is checked: SPE Effective Date
Definitions of Self-Certification Categories
Issue Date
License #
Issuing State
Medical Certification Expiration Date
Suffix
Expiration Date
Expiration Date
Non-excepted Interstate (NI) –
• All Class A, B, or C privately or self-employed commercial drivers who operate or expect to operate in interstate
commerce, and are subject to meet the federal medical standard and, therefore, are required to obtain a medical
examiner’s certificate
• All Class A, B, or C drivers who do not fall under any other category or who have been granted a federal vision or
diabetes exemption or a Skill Performance Evaluation (SPE)
Excepted Interstate (EI) –
• Drivers who operate or expect to operate in interstate commerce but engage exclusively in transportation or
operations that are not required to meet all or parts of the federal qualification requirements and are, therefore, not
required to obtain a medical examiner’s certificate
Examples of EI Drivers include:
 City, municipal, or state employed Commercial Driver's License holders
Non-excepted Intrastate (NA) –
• All Class A, B, or C privately or self-employed commercial drivers who only operate in intrastate commerce and are
subject to state driver qualification requirements
Examples of NA Drivers include:
 Drivers 18-21 years of age with a K restriction associated with their license to operate
 Drivers 21 and over with a W Restriction associated with their license to operate
Excepted Intrastate (EA) –
• Drivers who operate in intrastate commerce but engage exclusively in transportation or operations that are not
required to meet all or parts of the state driver qualification requirements and are, therefore, not required to obtain
a medical examiner’s certificate
Examples of EA Drivers include:
 City, municipal, or state employed Commercial Driver's License holders