Fillable Printable CDL Self-Certification Form - Michigan
Fillable Printable CDL Self-Certification Form - Michigan
CDL Self-Certification Form - Michigan
MichiganDepartmentofState
CDLSelf‐CertificationForm
Full Name: (Please Print)
Driver’s License Number:
Date of Birth:
CERTIFYING TO THE TYPE OF COMMERCIAL MOTOR VEHICLE (CMV) DRIVING I WILL DO AS REQUIRED IN 49 CFR PARTS 383 AND
391 (Choose only ONE of the following types.)
I will operate or expect to operate a CMV in the following manner:
Non-excepted interstate - I will operate a CMV outside of Michigan. I must also provide my medical certificate (DOT medical card).
Excepted interstate - I will operate a CMV outside of Michigan solely for an excepted purpose and am not legally required to have a
medical certificate (DOT medical card).
Non-excepted intrastate - I will operate a CMV solely within Michigan (intrastate commerce) and am legally required to have a medical
certificate (DOT medical card).
Excepted intrastate - I will operate a CMV solely within Michigan for an excepted purpose and am not legally require d to have a medical
certificate (DOT medical card).
I certify the information disclosed on this form is true. I understand making a false statement when applying for a driver’s license is a crime.
Signature: Date:
DRIVING TYPES
Non-excepted i nterstate. Operates a commercial motor vehicle outside of Michigan and must provide a legible copy to the Secretary of
State of one of the following medical certification documents:
A completed Medical Examiner’s Certificate signed by a medical professional. You must also keep this document w ith you until
January 30, 2014 when operating a commercial motor vehicle.
An FMCSA Skills Performance Evaluation d ocument and/or an FMCSA document listed in 49 CF R 381 Subpart C, authorizing
operation of a CMV. This document must be in your possession when operating a CMV.
Note: Operation of a CMV within state lines is considered interstate commerce if the origin and/or destination of the load crosses state
lines.
Excepted interstate. Operates a CMV outside of Michigan o nly for excepted purposes listed below.
Note: Operation of a CMV within state lines is considered interstate commerce if the origin and/or destination of the load crosses state
lines.
Excepted Interstate Purposes:
49 CFR §390.3(f) : State and federal transportation, occasional transportation of personal property not for compensation,
transportation of human corpses or sick/injured persons, fire trucks and rescue vehicles, commercial vehic les d esigned or used to
transport between 9 and 15 passengers (including the driver), transportation of propane w inter heating fuel.
49 CFR §391.2: Farm custom operations, apiarian industries (beekeepers se asonally transporting bees), certain farm vehicle d rivers.
49 CFR §391.68: Private motor carrier of passengers (nonbusiness).
49 CFR §398.3: Driver of migrant workers.
Non-excepted i ntrastate. O perates a CMV only within Michigan (intrastate commerce). Your medical certification and/or a Motor Carrier
Division M edical Waiver does not need to be provided to the Department of State. However, the medical certification and/or a Motor
Carrier Division Medical Waiver must be in your possession when operating a CMV.
Excepted intrastate. Operates a CMV only within Michigan (intrastate commerce) only for an excepted purpose listed below.
Excepted Intrastate Purpose:
MCL 480.15(2)-(5): A self-propelled implement of husbandry or an implement of husbandry being drawn by a farm tractor or another
implement of husbandry; public utility, telephone, and cable tel evision compan y service vehicles that do not meet the definition of a
CMV in 49 CFR part 383; or a public utility service vehicle used in cases of emergency .
Completeandreturnthisformandanyrelateddocumentsonline,byfaxormailorinpersonatanySecretaryofStateoffice.
FaxNumber:(517)636‐4359 Website:www.michigan.gov/CDL MailingAddress:MichiganDepartmentofState
CDLHelpDesk
7064CrownerDrive
CDLSelf‐CertWebform(Rev.10/13)
Lansing,MI48918
