Fillable Printable Cdl-5 Rev 1 2012 (5) Draft
Fillable Printable Cdl-5 Rev 1 2012 (5) Draft
Cdl-5 Rev 1 2012 (5) Draft
CDL-5 (Rev. 1/12)
State of North Carolina
North Carolina Department of Transportation
Division of Motor Vehicles
APPLICATION/CERTIFICATION
FOR COMMERCIALDRIVER LICENSE
District _____
Station _____
RACF _____
Original Renewal Duplicate
Name
(Last)
(First)
(Middle)
(Suffix)
North Carolina License Number:
Social Security Number:
Date of Birth:
Race:
White
American Indian
Black
Other
Sex:
Male Female
Height:
Ft. In.
U.S. Citizen
Yes No
Hair Color:
Bl
onde
Black
Red
Eye Color:
Blue
Gray
Hazel
Gray
White
Bald
Pink
Black
Green
Brown
Sdy
Dichromatic
Other
Brown
Residence Address:
Mailing Address:
City:
State:
Zip:
County:
City
:
State:
Zip:
County:
Class CDL Applying For
Endorsements
Organ Donor
A
B
C
H
T
S
P
N
X
M
Yes
No
Are you transferring to North Carolina? Y
N
If yes, list all states and license numbers where you have been licensed in the last 10 years.
Previo
us State and Number
Previous State and Number
Previous State and Number
Previous State and Number
Previous State and Number
Previous State and Number
Previous State and Number
Previous State and Number
INITIAL BELOW: All applicants must certify to Items 1, 2, 3 or 4, whichever is applicable.
You must certify that you operate or expect tooperatein one of the following applicablecertifications.
1. ________NON-EXCEPTED INTERSTATE: operates or expects to operate in interstate commerce, is both subject to and
meets the qualification requirements under 49 CFR part 391, and is required to obtain a medical examiner’s certificate by
391.45.
2. ________EXCEPTED INTERSTATE: operates or expects to operate in interstate commerce, butengages exclusively in
transportation or operations excepted under 49 CFR 390.3(f), 391.2, 391.68 or 398.3from all orparts of the qualification
requirements of49 CFR part 391, and is, therefore, not requiredto obtaina medical examiner’s certificate.
3. ________NON-EXCEPTED INTRASTATE: operates only inintrastate commerce and, therefore, is subject to State driver
requirements.
4. ________EXCEPTED INTRASTATE: operates in intrastate commercebut, engages exclusively in transportationor
operations excepted from all or parts of the State driver qualification requirements.
All applicants must initial Items 5 and 6. Only initial line 7 when a skills test is required.
5. ________I certify that I am not subject to disqualification under Title 49, Code of Federal Regulations, Part 383.51, of any
license suspension, revocation, or cancellation under StateLaw.
6. ________I certify that I donot have a driver’s license from morethan one state or jurisdiction.
7.________I certify that the vehicle inwhich I will take the commercial motor vehicle skills test is representative of the type
and size motor vehicle I operate or expect to operate.
I certify that the information provided in this application is correct and true to the best of my knowledge.
My signaturerepresents consent to release my driving record information. I understand that supplying
false information may result in the suspension of my driving privilege. Ialso understand that the
application fee required when submitting this application is non-refundable, and all test scores are valid
for 90 days.
Signature:Date:
