Transcription of SELF-CERTIFICATION FORM
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Example: bachelor of science
SELF-CERTIFICATION FORM
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.
medical card. If/When you return to driving a commercial vehicle and you need to carry a medical card, you must resubmit a DL-11CD, Self-Certification Form, along with a copy of your valid medical card. NOTE: You must be at least 21 years of age or older to operate a commercial vehicle in non-excepted interstate transportation. A “K”
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