Fillable Printable CDL Holder Self-Certification - New Jersey
Fillable Printable CDL Holder Self-Certification - New Jersey
CDL Holder Self-Certification - New Jersey
Name of Driver: _________________________ New Jersey Driver License Number: _____________________
Are you submitting a copy of your medical certificate? YES NO (please circle yes or no)
If there are no chang es from y our previous self-certification, please check this box: (and sign below)
Note: Only Class A, B, or C drivers that check the box for category 1 or 3 on the self-certificationcateg orie s listed
below must submit a copy of their medical certificate; however allCDL holders, Class A, B, or C drivers must
submit thiscertification.
Please check only one of the following self-certification categories that apply to you.
I certify my commercial transportation is:
Category 1: Interstate and subjectto 49 C.F.R. part 391. (Medical certificate andself-certificationmust be
submitted)
•All Class A, B, and C drivers who do NOT fall under any of the other categories.
•All Class A, B, and C drivers granted a federal vision or diabetes exemption; or SPE-limb impairment
Skill Performance Evaluation.
Category 2: Interstate but operating exclusively in transportation or operations excepted under 49 C.F.R.
390.3(f), 391.2, or 391.68 (self-certificationmu st be subm itted ).
•Transportation performed by the federal government, a state, or any political subdivision of a state.
(Note:The Motor Vehicle Commission requires ALLP (passenger) endorsement holders, including
govern ment worke rs, to submit a valid medical certificatein orderto maintain the P endorsement
on their CDL. N.J.A.C. 13:21-14.5(c)(6)
•The transportation of human corpses or sick and injured persons.
•The operation of fire trucks and rescue vehicles while involved in emergency and related operations.
•Apiar ian indu st ries (B eek ee pers ).
•Farm vehicle drivers operating within a 150 mile radiusof the farm.
Category 3
: Intrastate and subject to state driver qualification requirements. (Medica l c er tific ate and
self-certificationmu st be sub m itted).
•All Class A, B, and C drivers who do NOT fall under any of the other categories.
Category 4: Intrastate, but operating exclusively in transportation or operations excepted from all or part of
the state driver qualification requirements (self-certificationmust be submitted).
•Transportation performed by the federal government, a state, or any political subdivision of a state.
(Note:The Motor Vehicle Commission requires ALLP (passenger) endorsement holders, including
governmentworkers, to submit a valid medical certificate in order to maintain the P endorsement
on their CDL. N.J.A.C. 13:21-14.5(c)(6)
•The transportation of human corpses or sick and injured persons.
•The operation of fire trucks and rescue vehicles while involved in emergency and related operations.
•Apiar ian indu st ries (B eek ee pers ).
•Farm vehicle drivers operating withina 150 mile radius of the farm.
Pursuant to 49 C.F.R. 383.71, I hereby certifythat the foregoing is true; I understand that if the information I
provided is willfully false, I am subject to punishment.
____________________________________ _____________
Driver’s SignatureDate
New Jersey Motor Vehic le Co mmission
CDL/Bus Unit
PO Box 685
Trenton, NJ08666
On the Road to Excellence
Visit us at www.njmvc.gov
New Jersey is an Equal Opportunity Employer
New Jersey
Mot or Vehicle Com mission
CDL Holder Self-Certification
