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MINNESOTA DEPARTMENT OF PUBLIC SAFETY DRIVER AND …

PS33203-06 (03/2021)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 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?YesNoYesNoAll CDL holders with a school bus endorsement MUST submit a current medical examiner's certificate from a certified medical 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. If there is a change in your medical status or interstate/intrastate status you MUST provide a new self-certification 1 of 2(Checking more than one category box will delay processing this form.)

medical waiver, if applicable, online: drive.mn.gov, by mail: Driver and Vehicle Services Division, 445 Minnesota Street, Suite 175, St. Paul, MN 55101-5175 or in person at any driver exam station or driver license office that accepts applications. Refer to the Driver and Vehicle Services Website for a list of locations.

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