Form R-314 "State Medical Waiver Application" - Connecticut

What Is Form R-314?

This is a legal form that was released by the Connecticut Department of Motor Vehicles - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2017;
  • The latest edition provided by the Connecticut Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form R-314 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Motor Vehicles.

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Download Form R-314 "State Medical Waiver Application" - Connecticut

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STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
60 STATE STREET
WETHERSFIELD, CONNECTICUT 06161-1013
On The Web At ct.gov/dmv
STATE MEDICAL WAIVER APPLICATION
PART 1 APPLICANT INFORMATION
APPLICANT'S NAME
(Last)
(First)
(Initial)
APPLICATION TYPE
TYPE OF VARIANCE
NEW
RENEWAL
DIABETES
LIMB
ADDRESS
(Number and Street)
OPERATOR LICENSE NUMBER
VISION
OTHER
(City/Town)
(State)
(Zip Code)
DATE OF BIRTH
TELEPHONE NUMBER
EXPERIENCE: NUMBER OF YEARS DRIVING EACH TYPE OF VEHICLE
BUSES
STRAIGHT TRUCKS
TRACTOR-TRAILER COMBINATIONS
OTHER
PART 2 MOTOR CARRIER/CO-APPLICANT INFORMATION
UNEMPLOYED (SKIP TO SECTION 3)
U.S. DOT NUMBER
MOTOR CARRIER'S NAME
CONTACT PERSON (Print)
ADDRESS
(Number and Street)
(City/Town)
(State)
(Zip Code)
TELEPHONE NUMBER
PART 3 TYPE OF OPERATION IN CONNECTICUT ( MUST BE COMPLETED IN ITS ENTIRETY)
DESCRIPTION OF VEHICLES APPLICANT WILL OPERATE IN CONNECTICUT:
AVERAGE PERIOD OF TIME APPLICANT WILL BE DRIVING AND/OR ON DUTY, PER DAY
TYPE OF COMMODITIES OR CARGO TO BE TRANSPORTED
FOR PASSENGER-CARRYING VEHICLE(S), SEATING CAPACITY OF VEHICLE(S):
TYPE OF BRAKE SYSTEM:
TRANSMISSION TYPE
AUXILIARY TRANSMISSION
IF YES, NUMBER OF FORWARD
SPEEDS
AUTOMATIC
NO
YES
MANUAL, NUMBER OF SPEEDS
REAR AXLE
STEERING
SINGLE SPEED
TWO SPEED
THREE SPEED
MANUAL
POWER ASSISTED
DESCRIPTION OF TYPE(S) OF TRAILER(S)
CARGO TANK
DROP FRAME
FLATBED
LOWBOY
POLE
VAN
OTHER
PART 4. CERTIFICATION
MOTOR CARRIER'S AUTHORIZED AGENT'S CERTIFICATION: I hereby certify that the above applicant is qualified under the Federal Motor Carrier
Safety regulations, Part 391, and in accordance with the Connecticut General Statutes, the Regulations of Connecticut State Agencies, and the standards
and procedures adopted by the Department of Motor Vehicles.
NAME AND TITLE OF MOTOR CARRIER'S AUTHORIZED AGENT (Print)
SIGNATURE
DATE
X
APPLICANT'S CERTIFICATION: I hereby certify that I am qualified under the Federal Motor Carrier Safety regulations, Part 391, Qualifications of Drivers,
and in accordance with the Connecticut General Statutes, the Regulations of Connecticut State Agencies, and the standards and procedures adopted by the
Department of Motor Vehicles.
APPLICANT'S SIGNATURE
DATE
X
MAIL TO: Department of Motor Vehicles, Driver Services Division, 60 State Street, Wethersfield, CT 06161-1013
R-314 Rev. 11-2017
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
60 STATE STREET
WETHERSFIELD, CONNECTICUT 06161-1013
On The Web At ct.gov/dmv
STATE MEDICAL WAIVER APPLICATION
PART 1 APPLICANT INFORMATION
APPLICANT'S NAME
(Last)
(First)
(Initial)
APPLICATION TYPE
TYPE OF VARIANCE
NEW
RENEWAL
DIABETES
LIMB
ADDRESS
(Number and Street)
OPERATOR LICENSE NUMBER
VISION
OTHER
(City/Town)
(State)
(Zip Code)
DATE OF BIRTH
TELEPHONE NUMBER
EXPERIENCE: NUMBER OF YEARS DRIVING EACH TYPE OF VEHICLE
BUSES
STRAIGHT TRUCKS
TRACTOR-TRAILER COMBINATIONS
OTHER
PART 2 MOTOR CARRIER/CO-APPLICANT INFORMATION
UNEMPLOYED (SKIP TO SECTION 3)
U.S. DOT NUMBER
MOTOR CARRIER'S NAME
CONTACT PERSON (Print)
ADDRESS
(Number and Street)
(City/Town)
(State)
(Zip Code)
TELEPHONE NUMBER
PART 3 TYPE OF OPERATION IN CONNECTICUT ( MUST BE COMPLETED IN ITS ENTIRETY)
DESCRIPTION OF VEHICLES APPLICANT WILL OPERATE IN CONNECTICUT:
AVERAGE PERIOD OF TIME APPLICANT WILL BE DRIVING AND/OR ON DUTY, PER DAY
TYPE OF COMMODITIES OR CARGO TO BE TRANSPORTED
FOR PASSENGER-CARRYING VEHICLE(S), SEATING CAPACITY OF VEHICLE(S):
TYPE OF BRAKE SYSTEM:
TRANSMISSION TYPE
AUXILIARY TRANSMISSION
IF YES, NUMBER OF FORWARD
SPEEDS
AUTOMATIC
NO
YES
MANUAL, NUMBER OF SPEEDS
REAR AXLE
STEERING
SINGLE SPEED
TWO SPEED
THREE SPEED
MANUAL
POWER ASSISTED
DESCRIPTION OF TYPE(S) OF TRAILER(S)
CARGO TANK
DROP FRAME
FLATBED
LOWBOY
POLE
VAN
OTHER
PART 4. CERTIFICATION
MOTOR CARRIER'S AUTHORIZED AGENT'S CERTIFICATION: I hereby certify that the above applicant is qualified under the Federal Motor Carrier
Safety regulations, Part 391, and in accordance with the Connecticut General Statutes, the Regulations of Connecticut State Agencies, and the standards
and procedures adopted by the Department of Motor Vehicles.
NAME AND TITLE OF MOTOR CARRIER'S AUTHORIZED AGENT (Print)
SIGNATURE
DATE
X
APPLICANT'S CERTIFICATION: I hereby certify that I am qualified under the Federal Motor Carrier Safety regulations, Part 391, Qualifications of Drivers,
and in accordance with the Connecticut General Statutes, the Regulations of Connecticut State Agencies, and the standards and procedures adopted by the
Department of Motor Vehicles.
APPLICANT'S SIGNATURE
DATE
X
MAIL TO: Department of Motor Vehicles, Driver Services Division, 60 State Street, Wethersfield, CT 06161-1013
R-314 Rev. 11-2017