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

1 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. 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.

2 NOTE: You must be at least 21 years of age or older to operate a commercial vehicle in non-excepted interstate transportation. A K . restriction will be added to your license for any intra-state driving type. Please check only one of the following SELF-CERTIFICATION driving types that apply to you. I certify that I drive or expect to drive a commercial vehicle in: NI I drive a commercial vehicle both in and outside the boundaries of Pennsylvania, and I currently carry a Medical Examiner's Certificate (DOT PHYSICAL CARD). Please enlarge your Medical Examiner's Certificate to 5 inches by 7 inches and make sure that all of the health care provider information is complete and legible. NA I drive a commercial vehicle only within the boundaries of Pennsylvania, and I currently carry a Medical Examiner's Certificate (DOT PHYSICAL CARD).

3 Please enlarge your Medical Examiner's Certificate to 5 inches by 7 inches and make sure that all of the health care provider information is complete and legible. EI I drive a commercial vehicle both in and outside the boundaries of Pennsylvania, and I DO NOT carry a Medical Examiner's Certificate. EA I drive a commercial vehicle only within the boundaries of Pennsylvania, and I DO NOT carry a Medical Examiner's Certificate. ARE YOU SUBMITTING A COPY OF YOUR MEDICAL CERTIFICATE? r YES r NO. To ensure the prompt processing of your Medical Examiner's Certificate as required by the Federal Motor Carrier Safety Regulations, when you copy your wallet card please enlarge the copy to 5 inches by 7 inches and make sure that all of the health care provider information is complete and legible.

4 These steps will ensure your information is added to our system correctly and reduce the chance of the information being returned to you for clarification. I certify under penalty of law that all commercial certifications and information contained herein are true and correct. X. SIGN. HERE. (SIGNATURE IN INK) DATE. Please mail the SELF-CERTIFICATION form and medical certificate (if applicable) to: Bureau of Driver Licensing 69008 Harrisburg, PA 17106-9008. 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 check one of the SELF-CERTIFICATION Driving Types on the form . How do I know what SELF-CERTIFICATION Driving Type I should check? NI - Non-Excepted Interstate Transportation: Interstate drivers who are subject to the Federal Physical Qualifications and Examination regulations.

5 A Medical Examiner's Certificate must accompany this form . Drivers who are at least 21 years of age or older. All Class A, B and C commercial drivers who engage in interstate commerce while transporting goods or providing services. All Class A, B and C commercial drivers who have been granted a federal vision or diabetes exemption, or who have successfully completed a Skills Performance Evaluation (SPE). School bus drivers employed by a school transportation provider/contractor who transport students for any purpose other than home to school/school to home, , out of state for a field trip. NA - Non-Excepted Intrastate Transportation: Intrastate drivers who are subject to the Federal Physical Qualifications and Examination regulations. A Medical Examiner's Certificate must accompany this form .

6 All Class A, B and C commercial drivers who operate commercial motor vehicles in intrastate commerce while transporting goods or providing services. Drivers who transport hazardous materials in intrastate commerce. Drivers who transport personal property for compensation. Drivers of migrant workers (must meet minimum medical standards only; 49 CFR ). EI - Excepted Interstate Transportation: Interstate drivers who are not subject to the Federal Physical Qualifications and Examination regulations. Therefore, a Medical Examiner's Certificate is not required. Drivers who are employed by the Federal government, a state, or any political subdivision of a state who engage in interstate commerce. School bus drivers employed by a school district who transport students for any purpose other than home to school/school to home, , out of state field trip.

7 *School bus drivers are still required to comply with the School Bus Driver's Physical Examination required by Title 67, Chapter 71. School bus drivers employed by either a school district or a school transportation provider/contractor who during normal home to school/school to home trips transport students out of state. *School bus drivers are still required to comply with the School Bus Driver's Physical Examination required by Title 67, Chapter 71. Drivers who operate vehicles in interstate commerce that have a Gross Vehicle Weight Rating (GVWR) of 10,001 to 26,000 lbs., do NOT transport hazardous materials that require placarding, and are NOT designed to transport 16 or more persons, including the driver. *Although not tied to the commercial license, drivers of these vehicles are required to carry a Medical Examiner's Certificate.

8 Drivers who occasionally transport personal property not for compensation, nor in the furtherance of a commercial enterprise, who engage in interstate commerce. Drivers who transport human corpses or sick and injured persons across state lines. Drivers who operate fire trucks and rescue vehicles while involved in emergency and related operations who engage in interstate commerce. Drivers who operate 9 to 15 passenger vans (including the driver) weighing less than 26,001 GVWR not for compensation who engage in interstate commerce. Drivers who work in the apiarian industry (Beekeepers) who engage in interstate commerce. Drivers who work in farm custom operations (Custom Harvesters) who engage in interstate commerce. Drivers of farm vehicles who engage in interstate commerce while operating within a 150 mile radius of the farm.

9 Drivers who transport passengers for non-business related purposes and not for compensation who engage in interstate commerce, , organizations exempt from the Internal Revenue Code that provide transportation for their members. Drivers who operate in interstate commerce while delivering emergency supplies of propane winter heating fuel or responding to a pipeline emergency. EA - Excepted Intrastate Transportation: Intrastate drivers who are not subject to the Federal Physical Qualifications and Examination regulations. Therefore, a Medical Examiner's Certificate is not required. Drivers who are employed by the Federal government, a state, or any political subdivision of a state who operate in intrastate commerce. Inspection mechanics who operate within a 25 mile radius of the maintenance facility for the purpose of conducting a road test as required under Chapter 175 (relating to vehicle equipment and inspection).

10 School bus drivers who transport students for any purpose within the boundaries of Pennsylvania. *School bus drivers are still required to comply with the School Bus Driver's Physical Examination required by Title 67, Chapter 71. Drivers who operate vehicles in intrastate commerce that have a GVWR of 17,001 to 26,000 lbs., do NOT transport hazardous materials that require placarding, and are NOT designed to transport 16 or more persons, including the driver. * Although not tied to the commercial license, drivers of these vehicles are required to carry a Medical Examiner's Certificate. Drivers who occasionally transport personal property not for compensation, nor in the furtherance of a commercial enterprise, in intrastate commerce. Drivers who transport human corpses or sick and injured persons in intrastate commerce.