Commercial Driver License Medical Self-certification Form - Minnesota

Print Name (First, Middle, Last) Date of Birth (mm/dd/yyyy)

Minnesota Driver's License Number:

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.

I certify my commercial operating status is--check only one category box below:

1. Are you submitting a copy of your medical examiner's certificate from a certified medical examiner?

2. Are you submitting a copy of a medical waiver?

Yes No

Driver Information:

All CDL holders with a school bus endorsement MUST submit a current medical examiner's certificate from a certified medical

examiner.

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. Refer to the Tennessen Warning on the back of this form.

If you have any questions or concerns, contact Driver and Vehicle Services by phone (651) 297-5029.

If there is a change in your medical status or interstate/intrastate status you MUSTprovide a new self-certification form.

Please submit this completed self-certification form and your medical examiner's certificate from a certified medical examiner

and/or medical waiver, if applicable by mail: Driver and Vehicle Services Division, 445 Minnesota Street, Suite 175, St. Paul,

MN 55101-5175, by fax to (651) 297-4447 or in person at any driver exam station or driver license office that accepts

Phone: (651) 297-5029

Instructions:

(Current medical examiner's certificate from a certified medical examiner must be submitted).

(Current medical examiner's certificate from a certified medical examiner must be submitted).