SELF-CERTIFICATION FORM - dot.state.pa.us

← Back to document page

DL-11CD (4-18). SELF-CERTIFICATION form . PLEASE READ IMPORTANT INFORMATION ON THE REVERSE SIDE. CHECK APPLICABLE BOX r INITIAL self CERTIFICATION r CHANGE self CERTIFICATION PREVIOUSLY REPORTED. DRIVER INFORMATION. DRIVER'S LICENSE NUMBER LAST NAME(S) JR/ETC. FIRST NAME MIDDLE NAME. DATE OF BIRTH TELEPHONE NUMBER (8:00 to 4:30 ) E-MAIL ADDRESS (if applicable). MONTH DAY YEAR. If you are not currently working as a commercial driver but would like to keep your CDL, you must submit the below certification. If you select either the EA or EI box, you will be able to keep your CDL without submitting a current medical card.

Self-Certification Driving Type Chart All Class A, B, or C (CDL) License holders and all drivers applying for a Class A, B, or C permit must

  Form, States, Self, Certifications, Self certification, Self certification form