Self-Certification Affidavit for Commercial Driver License

The execution of this form is for self-certification purposes. Affiant must submit this form to Alabama’s Department of Public Safety to avoid the revocation of her/his commercial driver license.Download

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Failure to return this form to the Alabama 	Law Enforcement Agency	 will result in the cancellation of 	
your commercial driver license.	 	
Self	-Certification Affidavit (please print)	 	
Name of Driver:	  	 	 	 	 	Alabama License No.:	 	 	 	 	 	
IMPORTANT	: Recent changes in federal regulations 49 CFR 383, 384, 390 and 391 require drivers of 	
commercial motor vehicles to certify the type of operation they’re engaged in. Effective January 30, 
2012, all Class A, B, or C drivers must submit this affidavit. 	*If 	you check the first self	-certification box 	
below, you must also submit a copy of your current medical card/certificate and always maintain a 
current medical card/ certificate on file with ALEA.*	 	
Are you submitting a copy of your medical card/certificate?  	  YES 	 	NO 	 	(Please circle yes or no)	 	
Please check only one of the following Self	-Certification categories that apply to you.	 	
 
I certify my commercial transportation is:	 	
 Non	-excepted Interstate	 and subject to 49 CFR part 391. 	*I am required to carry a DOT M	edical 	
Card/Certificate*	 (medical card/certificate and this affidavit must be submitted)	 	
 	
 Excepted Interstate	, but operating exclusively in transportation or operations excepted under 	
49 CFR 390.3 (f), 391.2, 391.68, or 398.3	 *I am NOT required to carry a 	DOT Medical 	
Card/Certificate*	 (only this affidavit must be submitted)	 Examples of excepted categories: 	
Transportation performed by Federal and State Government and Churches. For a complete list 
of excepted categories, please refer to the 49 CFR codes above	. 	
 	
 Non	-excepted Intrastate	 and subject to Alabama driver qualification requirements. 	*My CDL 	
has a W	-Restriction due to an Alabama issued Medical Waiver*	 (only this affidavit must be 	
submitted)	 	
 	
 Excepted Intrastate	, but operating exclusively in transportat	ion or operations excepted from all 	
or part of the State driver qualification requirements. 	(only this affidavit must be submitted)	 	
  	 	 	 	 	 	 	 	 	 	 	 	 	 	
Driver’s Signature	 	 	 	 	 	 	 	Date	 	
Please mail or fax the medical card/certificate (if applicable) and this Self	-Certification affidavit no later 	
than 10 days prior to renewing your commercial driver license. Mail or fax to	 	
Alabama 	Law Enforcement Agency	 	 	 	For questions, please e	-mail: 	 	
Driver License Division 	  	 	 	 	e-mail: 	[email protected]	  	
CDL Unit P.O. Box 1471 	  	 	 	 	334	-353	-1980 	– fax number 	 	
Montgomery, Al 36102	-1471