"Self-certification Affidavit Form" - Delaware

Self-certification Affidavit Form is a legal document that was released by the Delaware Division of Motor Vehicles - a government authority operating within Delaware.

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Download "Self-certification Affidavit Form" - Delaware

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Self-Certification Affidavit
Name: __________________________________________________Date of Birth: _________________
Last
First
Middle
Delaware Driver License Number: ________________________________
Home Phone: ________________________ Cell Phone: __________________________
Are you submitting a copy of your medical certificate?
YES
NO
(please circle one)
(
Note: Only Class A, B or C CDL holders selecting Category 1 must submit a copy of the medical certificate.)
Please select only one of the following Self-Certification categories below.
I certify my commercial transportation is:
Category 1-Non Excepted Interstate; Interstate commerce driver and subject to 49 CFR 391 and
required to obtain certificate by 49 CFR 391.45. (Medical certificate and affidavit must be
submitted.)
* If you fall under any of the below categories while also operating a vehicle that falls under
category 1, you must select category 1.
Category 2-Excepted Interstate; Interstate commerce driver operating exclusively in transportation
or operations excepted under 49 CFR 390.3 (f), 391.2, 391.68, 398.3. (Only the affidavit must be
submitted).
Category 3- Non-Excepted Intrastate; Intrastate only commerce driver subject to State driver
qualification requirements. (Must present to DMV to obtain a new license document with “K”
restriction if your license does not already have one.)
Category 4- Excepted Intrastate; (Non-CDL Holder Class A or B Only) Intrastate only
commerce driver who is excepted from all or parts of the State driver qualification requirements.
________________________________
__________________________
Driver Signature
Date
Please email, mail or fax the Medical Examiner Certificate and Self-Certification to:
Email: DOT_DECDLMEDCERT@state.de.us
Mail:
Delaware Division of Motor Vehicles
Attn: CDL Department
P.O. Box 698
Dover, DE 19903
(302)739-2602 Attn: CDL Department
Fax:
(Please ensure that all information is legible on the documents you are faxing)
Self-Certification Affidavit
Name: __________________________________________________Date of Birth: _________________
Last
First
Middle
Delaware Driver License Number: ________________________________
Home Phone: ________________________ Cell Phone: __________________________
Are you submitting a copy of your medical certificate?
YES
NO
(please circle one)
(
Note: Only Class A, B or C CDL holders selecting Category 1 must submit a copy of the medical certificate.)
Please select only one of the following Self-Certification categories below.
I certify my commercial transportation is:
Category 1-Non Excepted Interstate; Interstate commerce driver and subject to 49 CFR 391 and
required to obtain certificate by 49 CFR 391.45. (Medical certificate and affidavit must be
submitted.)
* If you fall under any of the below categories while also operating a vehicle that falls under
category 1, you must select category 1.
Category 2-Excepted Interstate; Interstate commerce driver operating exclusively in transportation
or operations excepted under 49 CFR 390.3 (f), 391.2, 391.68, 398.3. (Only the affidavit must be
submitted).
Category 3- Non-Excepted Intrastate; Intrastate only commerce driver subject to State driver
qualification requirements. (Must present to DMV to obtain a new license document with “K”
restriction if your license does not already have one.)
Category 4- Excepted Intrastate; (Non-CDL Holder Class A or B Only) Intrastate only
commerce driver who is excepted from all or parts of the State driver qualification requirements.
________________________________
__________________________
Driver Signature
Date
Please email, mail or fax the Medical Examiner Certificate and Self-Certification to:
Email: DOT_DECDLMEDCERT@state.de.us
Mail:
Delaware Division of Motor Vehicles
Attn: CDL Department
P.O. Box 698
Dover, DE 19903
(302)739-2602 Attn: CDL Department
Fax:
(Please ensure that all information is legible on the documents you are faxing)
Self-Certification Category Guide
Category 1: Interstate driver operating in interstate commerce/crosses state lines.
Action: Copy of medical examiner certificate/variance or waiver must be supplied to the Division
of Motor Vehicles (DMV).
All Class A, B and C drivers who do NOT fall under any other category below.
All Class A, B and C drivers granted a federal vision or diabetes exemption; or limb
impairment Skill Performance Evaluation. (Exemption/Waiver must be carried at all
times)
Category 2: Interstate exclusive driver operating in operations excepted under 49 CFR 390.3(f)_
Action: Medical examiner certificate is not supplied to the DMV.
* If you fall under this category and also operate a vehicle that falls under category 1, you must select
category 1.
If you operate ONLY the following excepted occupations:
School bus- Check category 2 if crossing state lines. Check category 3 if NOT crossing
state lines. (State DOE medical card must be carried at all times in both cases)
Occasional transportation of personal property by individuals not for compensation, nor
in the furtherance of a commercial enterprise.
The transportation of human corpses or sick and injured persons.
The operation of fire trucks and rescue vehicles while involved in emergency and related
operations.
Apiarian industry workers (Beekeepers)
Farm custom operations (Custom Harvesters)
Non-articulated farm vehicle drivers operating within a 150 mile radius of the farm.
Private motor carrier of passengers (non-business). For example, organizations exempt
from the Internal Revenue Code that provide transportation for their members.
Emergency delivery of propane winter heat fuel and pipeline response.
Drivers of migrant workers (must meet minimum medical standards only; 49 CFR 398.3)
Category 3: Intrastate exclusive driver and subject to state driver qualification requirements.
Action: Medical examiner certificate is not supplied to the DMV. Must have a “K” restricted
driver license.
If you fall under this category and also operate a vehicle that falls under category 1, you must
select category 1.
If you operate ONLY the following:
Delaware drivers granted a state waiver for vision and insulin controlled diabetes
(Restriction K, Intrastate only)
Drivers under the age of 21 operating vehicles over 26,001 pounds, vehicles designed to
transport 16 or more passengers including the driver, and/or school vehicles, (Restriction
K, Intrastate Only)
Category 4: Intrastate exclusive driver (Non-CDL Holder Class A or B Only)
Action: Medical examiner certificate is not supplied to the DMV.
If you fall under this category and also operate a vehicle that falls under
category 2, you must select category 2.
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