Fillable Printable Form MC-11A - Medical Certification Requirements for Commercial Drivers - New York

Form MC-11A - Medical Certification Requirements for Commercial Drivers - New York

MEDICAL CERTIFICATION REQUIREMENTS FOR COMMERCIAL DRIVERS

MC-11A (4/15)

It is your responsibility to keep an up to date medical certification on file with the Department of Motor Vehicles.

INSTRUCTIONS:

> STEP 1: Fill out your name, address and driver license number at the top of this form. If you do not provide your name,

address and driver license number, your form will not be accepted. Make sure your information is legible and

accurate.

> STEP 2: Compare the restrictions on your license to the restrictions required for your driving type (listed below) –

THE RESTRICTIONS MUST MATCH. If a restriction change is needed do not fill out this form.

You must go into your local DMV office and amend your license. A license amendment fee will apply.

> STEP 3: Select a driving type by placing an "X" in the box next to the type of driving that applies, or may apply to you.

You must choose

ONLY ONE driving type. Visit: http://www.dmv.ny.gov/cdl-medcert.htm for driving type information.

> STEP 4: If you select NA or NI as your driving type, you must

submit a complete, unexpired, legible photocopy of

your USDOT Medical Examiner's Card with

this form. If your Medical Examiner's Card is two-sided,

make sure you copy both sides. All copies should be on one side of a single standard 8 1/2" by 11" sheet of paper.

> STEP 5: Sign and mail this form with your Medical Examiner’s Card (if required) to:

NYS Department of Motor Vehicles

Medical Certification Unit - PO BOX 2601

Albany, NY 12220-0601

NON-EXCEPTED INTERSTATE (NI)- Current USDOT Medical Examiner's Card required.

You are age 21 or older and you operate or expect to operate interstate. Must not have K or A3 restrictions.

NON-EXCEPTED INTRASTATE (NA

) - Current USDOT Medical Examiner's Card required.

You are age 18 or older and you operate or expect to operate in NYS only. K restriction required

EXCEPTED INTRASTATE (EA)

- Current USDOT Medical Examiner's Card NOT required.

You are age 18 or older and you operate or expect to operate in Excepted Operation ONLY and in NYS ONLY.

K and A3 restrictions required.

EXCEPTED INTERSTATE (EI)

- Current USDOT Medical Examiner's Card NOT required.

You are age 18 or older and you operate or expect to operate interstate in Excepted Operation ONLY. A3 restriction required.

Acknowledgment:

The information I have given on this form and on any associated documents or proof submitted by me in

connection with this form are true, accurate, and complete. I understand that the information on this form and on any associated

documents submitted by me in connection with this form will be filed with the New York State Department of Motor Vehicles

(DMV) and recorded in the records of DMV. I understand that providing false, inaccurate or incomplete information may be the

basis for criminal prosecution and the revocation of my commercial driver license and/or non-commercial driving privileges.

Signature (required)

Name: __________________________________________________________

Address: __________________________________________________________

__________________________________________________________

Date: ______________________

Driver License Number:

DRIVING TYPES - CHOOSE ONLY ONE