Cdl Data Form PDF Details

Commercial Driver License (CDL) data form requirements vary from state to state. So what do you need to do when it comes time to renew your CDL? To start, be sure to check with your local DMV office or driver licensing authority for specific information on what is required in your area. generally, you will need to provide proof of identity, residency, and citizenship/legal status. You may also need to submit a medical certification and pass a knowledge test. Alternatively, some states offer the option of submitting a self-certification affidavit in lieu of the knowledge test. Contact your local DMV for more information on what is required in your area.

QuestionAnswer
Form NameCdl Data Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnebraska form dmv 06 104, A4, 3RD, A2

Form Preview Example

 

– CDL –

 

 

 

 

 

CDL DATA FORM

 

 

 

 

 

– CDL –

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

Social Security Number

COMPLETE INFORMATION BELOW – PLEASE PRINT

Month

 

 

Day

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST NAME

 

 

 

 

 

FIRST NAME

 

 

 

 

 

 

 

MIDDLE INITIAL

 

SUFFIX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT RESIDENTIAL ADDRESS REQUIRED (STREET ADDRESS OR ROUTE AND P.O. BOX)

 

CITY

 

 

 

 

 

 

 

STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT MAILING ADDRESS (IF DIFFERENT FROM RESIDENTIAL ADDRESS)

 

 

CITY

 

 

 

 

 

 

 

STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COUNTY

GENDER

 

HEIGHT

 

WEIGHT

 

EYE

 

 

HAIR

 

 

 

RACE

 

NUMBER

FT.

 

IN.

 

 

COLOR

 

 

COLOR

 

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

BLACK

AMERICAN INDIAN

OTHER

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

WHITE

ASIAN OR PACIFIC ISL. HISPANIC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For the purposes of complying with Neb. Rev. Stat. 60-484.04, I attest:

I am a citizen of the United States………………………………………………………………………………..

OR

I am not a citizen of the United States, but do have lawful status and agree to provide valid documentary evidence of such as outlined in 60-484.04…………………………………………..……………………………

__Yes __No

__Yes __No

Please answer questions A1 AND A2.

A1.

I hereby certify that the commercial motor vehicle in which I take any driving skills examination is

 

 

 

 

 

 

representative of the class of commercial motor vehicle that I operate or expect to operate………………...

 

 

Yes

 

No

A2.

I certify that I am not subject to any disqualification under 383.51, that my license is not suspended,

 

 

 

 

 

 

revoked or cancelled in this or any other State and that I do not have a driver’s license from more than one

 

 

 

 

 

 

State or jurisdiction…………………………………………………………………………………………...

__Yes

___No

Choose ONE of the following categories that apply to you (use chart to assist you in choosing correct category).

A.Interstate – Non-Excepted: Subject to federal medical/vision requirements - must provide DMV with current medical examiner’s certificate (card – NOT long form) and keep current with DMV……….……

B.Interstate – Excepted: Subject to DMV medical/vision requirements – answer questions #5-#7 below.………………………………...............................................................................................................

C.Intrastate – Non-Excepted: Subject to federal medical/vision requirements – NOT required to provide DMV with current medical examiner’s certificate…………………………………………………………

D.Intrastate – Excepted: Subject to DMV medical/vision requirements – answer questions #5-#7 below.……………………………………………………………………………………………………......

Answer question A3 OR A4.

Yes No

Yes __No

Yes __No

__Yes __No

A3.

I certify that I have not held a license (commercial or non-commercial) from any other State in the last ten

 

 

 

years…………………………………………………………………………………………………………..

__Yes

___No

A4.

I certify that I have held a license (commercial or non-commercial) from the following State(s) in the last

 

 

 

10 years………………………………………………………………………………………………………

__Yes

___No

 

Please list State(s):_____________________________________________________________________

 

 

 

Please list any other names you were known as while holding those license(s):______________________

 

 

 

_______________________, _________________________, ___________________________

 

 

Please answer the following motor voter/veteran designation/organ and tissue donation questions (answers are optional).

1A.

Do you wish to register to vote as part of this application process? (You only need to re-register if you

 

 

 

 

 

 

have changed your name, address or political party)………………………………………………………..

 

Yes

 

 

No

1B. Do you wish to have the word “Veteran” displayed on the front of your license to show that you served in the

 

 

 

 

 

 

armed forces of the United States? (To be eligible you must register with the Nebraska Department of

__Yes

___No

 

Veterans’ Affairs Registry)

 

 

 

 

 

 

2. Do you wish to be an organ and tissue donor?………………………………………………………………..

 

Yes

 

 

No

 

 

 

 

 

3.

Do you wish to receive any additional specific information regarding organ and tissue donation?…………

 

Yes

 

 

No

4.

Do you wish to donate $1 to promote the Organ and Tissue Donor Awareness and Education Fund?……..

 

Yes

 

 

No

You must answer the following medical questions if you answered “Yes” to questions B or D above. DO NOT answer the following questions if you answered “Yes” to questions A or C above.

5.Have you within the last three months (e.g. due to diabetes, epilepsy, mental illness, head injury, stroke,

heart condition, neurological disease, etc.):

 

A. lost voluntary control or consciousness (date:

)

B.experienced vertigo or multiple episodes of dizziness or fainting

C.disorientation..................................................................................................................................................................................................

D. seizures (date:

 

)

E.impairment of memory, memory loss....................................................................................................

6.Do you experience any condition which affects your ability to operate a motor vehicle due to loss or impairment of:

A.foot/leg ..................................................................................................................................................

B.upper body strength...............................................................................................................................

C.range of motion/mobility.......................................................................................................................

D.hand/arm................................................................................................................................................

E.neurological/neuromuscular disease......................................................................................................

7.Since the issuance of your last license/permit, has your health or medical condition worsened?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

DMV 06-105 7/14

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