Dds-1207 - Commercial Driver Self-Certification Form printable pdf download

THIS FORM IS ACCEPTED IN-PERSON AT A CSC ONLY.

COMMERCIAL DRIVER SELF-CERTIFICATION FORM

DRIVER LICENSE NUMBER

DATE OF BIRTH (MM/DD/YYYY)

APPLICANTS NAME (Last, First, MI)

ADDRESS

CITY, STATE, ZIP CODE

AREA CODE/ TELEPHONE NUMBER

EMAIL ADDRESS:

HOME (

)______________________________ OTHER (

)______________________________

FMCSA CERTIFICATIONS (INITIAL BESIDE APPLICABLE STATEMENT) - See Self-Certification Guidelines

Self-Certification

Non-Excepted Interstate - I certify that I will operate or expect to operate in interstate or foreign commerce, that I am subject

Categories A-D

to and meet the FMCSA driver qualification requirements under 49 CFR part 391, and I am required to obtain a medical

(Initial Only One)

examiner’s certificate. I also certify that I do not have an impairment of an arm, foot, or leg that interferes with the normal

tasks associated with the operation of a CMV. (Medical Certificate needed)

Non-Excepted Intrastate - I certify that I will operate entirely in intra state commerce only and that I meet the FMCSA driver

A, B – Medical Certificate

qualification requirements as defined in 49 CFR 391. I also certify that I do not have an impairment of an arm, foot, or leg

needed.

that interferes with the normal tasks associated with the operation of a CMV.(Medical Certificate needed)

Excepted Interstate - I certify that I will operate or expect to operate in interstate commerce, but engage exclusively in

C, D – Medical

transportation or operations excepted under 49 CFR §§390.3(f), 391.2, 391.68 or 398.3 from all or parts of the qualification

Certificate NOT

requirements of 49 CFR part 391, and I am therefore not required to obtain a medical examiner’s certificate. (Medical

needed.

Certificate not needed)

Excepted Intrastate - I certify that I will operate in city, county, state, or federal vehicle only, and I am exempt from the

FMCSA driver qualification requirements of 49 CFR 390.3(f). (Medical Certificate not needed)

Licenses, Disqualifications,

I certify that I am not subject to any disqualification defined in 49 CFR §383.51or any license suspension, revocation, or

and Withdrawals

cancellation pursuant to the laws of any State.

Initial, if Transfer From

I certify that I do not have a driver’s license from more than one State or jurisdiction.

Another State or First

Issuance

REQUIRED ACKNOWLEDGEMENT AND SIGNATURES (INITIAL BESIDE ALL STATEMENTS)

Under penalty of law, I swear or affirm that I am a resident of the State of Georgia or that I qualify for a Nonresident CDL, and the information provided on

this application is true and correct. I understand that it is illegal to make false, fictitious, or fraudulent statements on this application. I grant permission

to the Department of Driver Services (DDS) to verify information furnished to the Department through the release of any and all applicant information to

third parties which shall include, but not be limited to the U.S. Department of Homeland Security, the Federal Motor Carrier Safety Administration or other

public or private entities wherein such disclosure of the information by the Department is not prohibited by law.

I understand that the DDS will check my driving record through available national databases, including, but not limited to, the Commercial Driver License

Information System (CDLIS), for the purpose of determining my eligibility for issuance of the requested licenses or permits.

Print Name

Date

Applicant’s Signature

Document Type:

When Must I Update It?

Mail To:

Fax To:

Online At:

In-Person:

DDS

(770)918-6271