Cdl Physical Form Pa Details

In today's business world, it is more important than ever to have a professional and polished image. One way to achieve this is by using the right forms for your needs. The DL 11Cd form is a great option for businesses that want to create an air of professionalism. This form is used to document a meeting or conversation, and can be helpful for keeping track of important information. Knowing how to use this form effectively can help you make the most of your business interactions.

Listed below are some information about dl 11cd form. It is a good idea that you read this info before you begin filling out the file.

QuestionAnswer
Form NameDl 11Cd Form
Form Length2 pages
Fillable?Yes
Fillable fields13
Avg. time to fill out3 min 10 sec
Other namesself certification form dl 11cd, dl 11cd form, pa cdl phyfical form, dmv dl11cd

Form Preview Example

DL-11CD (8-13)

www.dot.state.pa.us

SELF-CERTIFICATION FORM

The most current version of this form can be found at www.dmv.state.pa.us

PLEASE TYPE OR PRINT ALL INFORMATION IN bLuE OR bLACk INk

PLEASE READ IMPORTANT INFORMATION ON THE REVERSE SIDE.

 

 

CHECk APPLICAbLE bOx

r INITIAL SELF CERTIFICATION r CHANgE SELF CERTIFICATION PREVIOuSLy REPORTED

 

 

 

 

 

 

 

 

DRIVER INFORMATION

 

 

 

 

 

DRIVER’S LICENSE NuMbER

 

 

LAST NAME(S)

 

JR/ETC

 

 

 

 

 

 

 

 

 

FIRST NAME

 

 

 

 

 

MIDDLE NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF bIRTH

 

 

TELEPHONE NuMbER (8:00 a.m. to 4:30 p.m.)

E-MAIL ADDRESS (if applicable)

 

 

 

 

 

 

 

 

 

MONTH

 

DAY

 

YEAR

 

 

 

 

 

 

 

 

 

 

 

 

If you are not currently working as a commercial driver but would like to keep your CDL, you must submit the below certification. If you select either the “EA” or “EI” box, you will be able to keep your CDL without submitting a current medical card. If/When you return to driving a commercial vehicle and you need to carry a medical card, you must resubmit a DL-11CD, Self-Certification Form, along with a copy of your valid medical card.

Please check only one of the following Self-Certification driving types that apply to you.

I certify that I drive or expect to drive a commercial vehicle in:

NI I drive a commercial vehicle both in and outside the boundaries of Pennsylvania, and I currently carry a Medical Examiner’s Certificate (DOT PHYSICAL CARD).

Please enlarge your Medical Examiner’s Certificate to 5 inches by 7 inches and make sure that all of the health care provider information is complete and legible.

NA I drive a commercial vehicle only within the boundaries of Pennsylvania, and I currently carry a Medical Examiner’s Certificate (DOT PHYSICAL CARD).

Please enlarge your Medical Examiner’s Certificate to 5 inches by 7 inches and make sure that all of the health care provider information is complete and legible.

EI

I drive a commercial vehicle both in and outside the boundaries of Pennsylvania, and I DO NOT carry a

 

Medical Examiner’s Certificate.

 

 

EA

I drive a commercial vehicle only within the boundaries of Pennsylvania, and I DO NOT carry a Medical

 

Examiner’s Certificate.

 

 

ARE YOu SubMITTING A COPY OF YOuR MEDICAL CERTIFICATE?

r YES

r NO

To ensure the prompt processing of your Medical Examiner’s Certificate as required by the Federal Motor Carrier Safety Regulations, when you copy your wallet card please enlarge the copy to 5 inches by 7 inches and make sure that all of the health care provider information is complete and legible. These steps will ensure your information is added to our system correctly and reduce the chance of the information being returned to you for clarification.

I certify under penalty of law that all commercial certifications and information contained herein are true and correct.

XSIGN

HERE

(SIGNATuRE IN INk)

DATE

Please mail the Self-Certification form and medical certificate (if applicable) to: Bureau of Driver Licensing • P.O.Box 69008 • Harrisburg, PA 17106-9008

Self-Certification Driving Type Chart

All Class A, b, or C (CDL) License holders and all drivers applying for a Class A, b, or C permit must check one of the Self-Certification Driving Types on the form.

How do I know what Self-Certification Driving Type I should check?

NI - Non-Excepted Interstate Transportation: Interstate drivers who are subject to the Federal Physical Qualifications and Examination regulations. A Medical Examiner’s Certificate must accompany this form.

All Class A, B and C commercial drivers who engage in interstate commerce while transporting goods or providing services.

All Class A, B and C commercial drivers who have been granted a federal vision or diabetes exemption, or who have successfully completed a Skills

Performance Evaluation (SPE).

School bus drivers employed by a school transportation provider/contractor who transport students for any purpose other than home to school/school to home, i.e., out of state for a field trip.

NA - Non-Excepted Intrastate Transportation: Intrastate drivers who are subject to the Federal Physical Qualifications and Examination regulations. A Medical Examiner’s Certificate must accompany this form.

All Class A, B and C commercial drivers who operate commercial motor vehicles in intrastate commerce while transporting goods or providing services.

Drivers who transport hazardous materials in intrastate commerce.

Drivers who transport personal property for compensation.

Drivers of migrant workers (must meet minimum medical standards only; 49 CFR 398.3).

EI - Excepted Interstate Transportation: Interstate drivers who are not subject to the Federal Physical Qualifications and Examination regulations. Therefore, a Medical Examiner’s Certificate is not required.

Drivers who are employed by the Federal government, a state, or any political subdivision of a state who engage in interstate commerce.

School bus drivers employed by a school district who transport students for any purpose other than home to school/school to home, i.e., out of state field trip. *School bus drivers are still required to comply with the School Bus Driver’s Physical Examination required by Title 67, Chapter 71.

School bus drivers employed by either a school district or a school transportation provider/contractor who during normal home to school/school to home trips transport students out of state. *School bus drivers are still required to comply with the School bus Driver’s Physical Examination required by Title

67, Chapter 71.

Drivers who operate vehicles in interstate commerce that have a Gross Vehicle Weight Rating (GVWR) of 10,001 to 26,000 lbs., do NOT transport hazardous materials that require placarding, and are NOT designed to transport 16 or more persons, including the driver. *Although not tied to the commercial license, drivers of these vehicles are required to carry a Medical Examiner’s Certificate.

Drivers who occasionally transport personal property not for compensation, nor in the furtherance of a commercial enterprise, who engage in interstate commerce.

Drivers who transport human corpses or sick and injured persons across state lines.

Drivers who operate fire trucks and rescue vehicles while involved in emergency and related operations who engage in interstate commerce.

Drivers who operate 9 to 15 passenger vans (including the driver) weighing less than 26,001 GVWR not for compensation who engage in interstate commerce.

Drivers who work in the apiarian industry (Beekeepers) who engage in interstate commerce.

Drivers who work in farm custom operations (Custom Harvesters) who engage in interstate commerce.

Drivers of farm vehicles who engage in interstate commerce while operating within a 150 mile radius of the farm.

Drivers who transport passengers for non-business related purposes and not for compensation who engage in interstate commerce, i.e., organizations exempt from the Internal Revenue Code that provide transportation for their members.

Drivers who operate in interstate commerce while delivering emergency supplies of propane winter heating fuel or responding to a pipeline emergency.

EA - Excepted Intrastate Transportation: Intrastate drivers who are not subject to the Federal Physical Qualifications and Examination regulations. Therefore, a Medical Examiner’s Certificate is not required.

Drivers who are employed by the Federal government, a state, or any political subdivision of a state who operate in intrastate commerce.

Inspection mechanics who operate within a 25 mile radius of the maintenance facility for the purpose of conducting a road test as required under Chapter 175 (relating to vehicle equipment and inspection).

School bus drivers who transport students for any purpose within the boundaries of Pennsylvania. *School bus drivers are still required to comply with the School Bus Driver’s Physical Examination required by Title 67, Chapter 71.

Drivers who operate vehicles in intrastate commerce that have a GVWR of 17,001 to 26,000 lbs., do NOT transport hazardous materials that require placarding, and are NOT designed to transport 16 or more persons, including the driver. * Although not tied to the commercial license, drivers of these vehicles are required to carry a Medical Examiner’sCertificate.

Drivers who occasionally transport personal property not for compensation, nor in the furtherance of a commercial enterprise, in intrastate commerce.

Drivers who transport human corpses or sick and injured persons in intrastate commerce.

Drivers who operate fire trucks and rescue vehicles while involved in emergency and related operations in intrastate commerce.

Drivers who operate 9 to 15 passenger vans (including the driver) weighing less than 26,001 GVWR not for compensation in intrastate commerce.

Drivers who work in the apiarian industry (Beekeepers) and operate in intrastate commerce.

Drivers who work in farm custom operations (Custom Harvesters) and operate in intrastate commerce.

Drivers of farm vehicles who engage in intrastate commerce.

Drivers who transport passengers for non-business related purposes and not for compensation in intrastate commerce, i.e., organizations exempt from the Internal Revenue Code, that provide transportation for their members.

Drivers who operate in intrastate commerce while delivering emergency supplies of propane winter heating fuel or responding to a pipeline emergency.

Visit us at www.dmv.state.pa.us or call us at:

In State: 1-800-932-4600 TDD: 1-800-228-0676 Out-of-State: 1-717-412-5300 TDD Out-of-State: 1-717-412-5380

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pa dot physical form empty fields to fill out

Complete the XSIGN, HERE, Please mail the Self-Certification, (SIGNATuRE IN INk), and DATE space using the data demanded by the system.

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