CDL Holder Self-Certification
Name of Driver: _________________________ New Jersey Driver License Number: _____________________
Are you submitting a copy of your medical certificate? YES NO
Note: Only Class A, B, or C drivers that check the box for category 1 or 3 on the self-certification categories listed
below must submit a copy of their medical certificate; however all CDL holders, Class A, B, or C drivers must
submit this certification.
Please check only one of the following self-certification categories that apply to you.
NOTE: ALL DRIVERS LESS THAN 21 YEARS OF AGE ARE ONLY ALLOWED TO OPERATE IN
INTRA-STATE COMMERCE AND MUST CHECK EITHER BOX 3 OR 4.
I certify my commercial transportation is:
Category 1: Interstate and subject to 49 C.F.R. part 391. (Medical certificate and self-certification must be
submitted)
All Class A, B, and C drivers who do NOT fall under any of the other categories.
All Class A, B, and C drivers granted a federal vision or diabetes exemption; or SPE-limb impairment
Skill Performance Evaluation.
Category 2: Interstate but operating exclusively in transportation or operations excepted under 49 C.F.R.
390.3(f), 391.2, or 391.68 (self-certification must be submitted).
Transportation performed by the federal government, a state, or any political subdivision of a state.
(Note: The Motor Vehicle Commission requires ALL P (passenger) endorsement holders, including
government workers, to submit a valid medical certificate in order to maintain the P endorsement
on their CDL. N.J.A.C. 13:21-14.5(c)(6)
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 industries (Beekeepers).
Farm vehicle drivers operating within a 150 mile radius of the farm.
Category 3: Intrastate and subject to state driver qualification requirements. (Medical certificate and
self-certification must be submitted).
All Class A, B, and C drivers who do NOT fall under any of the other categories.
Category 4: Intrastate, but operating exclusively in transportation or operations excepted from all or part of
the state driver qualification requirements (self-certification must be submitted).
Transportation performed by the federal government, a state, or any political subdivision of a state.
(Note: The Motor Vehicle Commission requires ALL P (passenger) endorsement holders, including
government workers, to submit a valid medical certificate in order to maintain the P endorsement
on their CDL. N.J.A.C. 13:21-14.5(c)(6)
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 industries (Beekeepers).
Farm vehicle drivers operating within a 150 mile radius of the farm.
Pursuant to 49 C.F.R. 383.71, I hereby certify that the foregoing is true; I understand that if the information I
provided is willfully false, I am subject to punishment.
____________________________________ _____________
Driver’s Signature Date
New Jersey Motor Vehicle Commission
CDL/Bus Unit
PO Box 685 Visit us at www.NJMVC.gov
Trenton, NJ 08666 New Jersey is an Equal Opportunity Employer
