Mn Self Certification Form – Fill Out and Use This PDF

MINNESOTA DEPARTMENT OF PUBLIC SAFETY

DRIVER AND VEHICLE SERVICES

Commercial Driver License Medical Self-certification Form

Instructions:

All commercial driver's license (CDL) holders, Class A, B or C, must complete and submit this self-certification form for initial, renewal or change in class application.

Drivers who check Category 1 or Category 3 below must also submit a current medical examiner's certificate from a certified medical examiner and any applicable waivers.

All CDL holders with a school bus endorsement MUST submit a current medical examiner's certificate from a certified medical examiner.

If there is a change in your medical status or interstate/intrastate status you MUST provide a new self-certification form.

Please submit this completed self-certification form and your medical examiner's certificate from a certified medical examiner and/or medical waiver, if applicable, online: drive.mn.gov, by mail: Driver and Vehicle Services Division, 445 Minnesota Street, Suite 175, St. Paul, MN 55101-5175 or in person at any driver exam station or driver license office that accepts applications.

Refer to the Driver and Vehicle Services Website for a list of locations.

If you have questions or need additional information, please contact DVS at (651) 297-5029 or (651) 282-6555 (TTY).

Driver Information

Please check only one of the following self-certification categories that apply to you:

I certify my commercial operating status is--check only one category box below:

(Checking MORE THAN ONE category box will delay processing this form.)

Category 1 - Non-exempt Interstate, subject to 49 C.F.R. § 391

(CURRENT MEDICAL EXAMINER'S CERTIFICATE FROM A CERTIFIED MEDICAL EXAMINER must BE SUBMITTED.)

Category 2 - Exempt Interstate, exempt from medical examination requirements of 49 C.F.R § 391

Category 3 - Non-exempt Intrastate, subject to state medical examination requirements of Minn. Stat. § 221

(CURRENT MEDICAL EXAMINER'S CERTIFICATE FROM A CERTIFIED MEDICAL EXAMINER must BE SUBMITTED.)

Category 4 - Exempt Intrastate, exempt from state medical examination requirements listed in Minn. Stat. § 221

Please answer the following two questions:

1. Are you submitting a copy of your medical examiner's certificate from a certified medical examiner?

Yes

No

2. Are you submitting a copy of a medical waiver? Yes No

Tennessen Warning

What is the purpose of supplying the requested information?

The Department of Public Safety ("DPS") collects the information on this form for record keeping purposes as required by the Minnesota Government Data Practices Act, Minn. Stat. § 13.04(2).

Am I required to provide the requested information?

You are not legally required to complete this form.

What will happen if I do not provide the requested information?

You can refuse; however, DPS cannot certify your medical status.

Who will have access to the requested information?

DPS may disclose personal information when it relates to the operation or use of a vehicle or to public safety. The use of personal information relates to public safety if it concerns the physical safety or security of drivers, vehicles, pedestrians or property. The personal information you provided to certify your medical status is classified by 18 U.S.C. § 2721 and Minn. Stat. § 171.12 and is subject to the disclosure in accordance with these laws.

X

Driver's Signature	Date

PS33203-06 (03/2021)

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In addition, your personal information may be disclosed as authorized by 18 U.S.C. § 2721.

Permissible Uses of Motor Vehicle Data as provided in

18 U.S.C. § 2721

For use by any government agency, including any court or law enforcement agency, in carrying out its functions, or any private person or entity acting on behalf of a federal, state or local agency in carrying out its functions.

For use in connection with matters of motor vehicle or driver safety theft; motor vehicle emissions; motor vehicle product alterations, recalls or advisories; performance monitoring of motor vehicles, motor vehicle parts and dealers; motor vehicle market research activities, including survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers.

For use in the normal course of business by legitimate business or its agents, employees or contractors, but only:

(A)to verify the accuracy of personal information submitted by the individual to the business or its agencies, employees or contractors; and

(B)if such information as so submitted is not correct or is no longer correct, to obtain correct information, but only for the purposes of preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest against, the individual.

For use in connection with any civil, criminal, administrative or arbitral proceeding in any federal, state or local court or agency or before any self-regulatory body, including the service of process, investigation in anticipation of litigation and the execution or enforcement of judgments and orders or pursuant to an order of a federal, state or local court.

For use in research activities, and for use in producing statistical reports, so long as the personal information is not published, re-disclosed or used to contact individuals.

For use by an insurer or insurance support organization, or by a self-insured entity or its agents, employees or contractors, in connection with claims investigation activities, antifraud activities, rating or underwriting.

For use in providing notice to the owners of towed or impounded vehicles.

For use by any licensed private investigative agency or licensed security service for any purpose permitted under this subsection.

For use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver's license that is required under the Commercial Motor Vehicle Safety Act, 49 U.S.C. §§ 31301-17.

For use in connection with the operation of private toll transportation facilities.

For any other use in response to requests for individual motor vehicle records if the state has obtained the express consent of the person to whom such personal information pertains.

For bulk distribution for surveys, marketing or solicitations if the state has obtained the express consent to whom such personal information pertains.

For use by any requester, if the requester demonstrates it has obtained the written consent of the individual to whom the information pertains.

For any other use specifically authorized under the law of the state that holds the record, if such use is related to the operation of a motor vehicle or public safety.

PS33203-06 (03/2021)

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