PS33203-07 (2/2024)
Minnesota Department of Public Safety
Driver and Vehicle Services
Commercial Driver’s License Medical Self- Certification Form
Instructions:
•
All commercial driver's license (CDL) holders, class A, B or C, must complete and submit this self-certification form for initial, renewal
or change in class application.
•
Drivers who check Category 1 or Category 3 below must also submit a current medical examiner's certificate from a certified medical
examiner and any applicable waivers.
•
All CDL holders with a school bus endorsement must submit a current medical examiner's certificate from a certified medical
examiner.
•
If there is a change in your medical status or interstate/intrastate status you must provide a new self-certification form.
When changing from intrastate to interstate, you must apply for a duplicate license and pay the appropriate fees.
•
Please submit this completed self-certification form and your medical examiner's certificate from a certified medical examiner and/or
medical waiver, if applicable, online: drive.mn.gov; by mail: Driver and Vehicle Services, 445 Minnesota Street, Suite 175, Saint Paul,
MN 55101-5175; or in person at any driver exam station or driver’s license office that accepts CDL applications. Refer to
drive.mn.gov for a list of office locations.
•
If you have questions or need additional information, please contact DVS at 651-297-5029 or 651-282-6555 (TTY).
Driver information
Name (first, middle, last)
Date of birth (mm/dd/yyyy)
Minnesota driver's license number: _______________________________________ example: A123-456-789-123
Please check only one of the following self-certification categories that apply to you:
I certify my commercial operating status is--check
only one category box below:
(Checking more than one category box will
delay processing this form.)
Category 1 -
Non-exempt Interstate, subject to Code of Federal Regulations title 49, part 391.
(
Current medical examiner's certificate from a certified medical examiner must be submitted.)
Category 2 -
Exempt Interstate, exempt from medical examination requirements of Code of Federal Regulations title 49, part 391.
Category 3 -
Non-exempt Intrastate, subject to state medical examination requirements of Minnesota Statutes, section 221.
(
Current medical examiner's certificate from a certified medical examiner must be submitted.)
Category 4 -
Exempt Intrastate,
exempt from state medical examination requirements listed in Minnesota Statutes, section 221.
Please answer the following two questions:
Are you submitting a copy of your medical examiner's certificate from a certified medical examiner?
Yes
No
Are you submitting a copy of a medical waiver?
Yes
No
Tennessen Notice
Why am I being asked to provide this information?
The Department of Public Safety Driver and Vehicle Services (DVS) division collects this information as required under Minnesota Statutes, section 171.162 and Code of Federal
Regulations, title 49, section 383.71 for purposes of compliance with Commercial Driver’s License (CDL) regulations.
Am I required to provide the requested information?
No. You are not legally required to provide this information to DVS.
What will happen if I do not provide the requested information?
If you refuse to provide the requested information, DVS will be unable to certify your medical status which could result in the loss of your CDL driving privilege.
What will happen if I provide the requested information and who will have access to the data?
DVS will use the information you provide on this form to update your medical certification status for your CDL driving privilege. Your name, date of birth, and driver’s license number are
considered private data and are classified by United States Code title 18, section 2721, Minnesota Statutes section 171.12, Minnesota Government Data Practices Act, Minnesota
Statutes, Chapter 13, and may be released in accordance with these laws. DVS may disclose personal information when it relates to the operation or use of a vehicle or to public safety.
The use of personal information relates to public safety if it concerns the physical safety or security of drivers, vehicles, pedestrians or property. This may include, but is not limited to,
providing your information to the Federal Motor Carrier Safety Administration and to your employer at their request.
X
Driver's signature
Date
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