DL 694 (REV. 6/2016) WWW
STATE OF CALIFORNIA
DEPARTMENT OF MOTOR VEHICLES
®
A Public Service Agency
CALIFORNIA COMMERCIAL DRIVER LICENSE
SELF-CERTIFICATION FORM
Commercial driver license (CDL) holders must inform the Department of Motor Vehicles (DMV) regarding the type of commercial
motor vehicle operation they drive in or expect to drive in with their CDL. Drivers are required to have a current medical
examination report on le with DMV to obtain a “certied” medical status as part of their driving record. CDL holders required to
have a ”certied” medical status who fail to provide and keep their medical examination up-to-date with DMV will become ”not-
certied” and they may lose their CDL.
SECTION 1 — COMMERCIAL DRIVER INFORMATION
DRIVER LICENSE NUMBER BIRTHDATE
LAST NAME FIRST NAME MIDDLE NAME
ADDRESS CITY STATE ZIP CODE
Please select only one of the following self-certication categories.
I certify my commercial driving is:
Non-Excepted Interstate (NI). I operate or expect to operate in interstate commerce and required to meet the qualication
requirements under (Code of Federal Regulations) CFR, Title 49 § 391.
Non-Excepted Intrastate (NA). I operate or expect to operate in intrastate commerce and required to meet the qualication
requirements under CFR, Title 49 § 391. I am restricted to driving commercially within California and the cargo must originate
and end within California.
California does not issue a commercial driver license excepted from driver qualication requirements.
Excepted Interstate (EI). I operate in excepted interstate commerce and am not required to meet federal qualication
requirements under CFR, Title 49 § 391.
Excepted Intrastate (EA). I operate in excepted intrastate commerce and am not required to meet federal qualication
requirements under CFR, Title 49 § 391.
SECTION 2 — CERTIFICATION
I certify that the information provided on this form is true and correct. I understand that under California Vehicle Code
(CVC) §20 it is unlawful to knowingly make any false statements, use a false or ctitious name, or to conceal material
fact in any document led with DMV. A violation of CVC §20 is a misdemeanor punishable by a $1000 ne or 6 months
imprisonment in a county jail or by both such ne and imprisonment. (CVC §§20, 40000.5, 42002)
SIGNATURE
X
DATE
This form may be submitted at any DMV eld ofce or mailed to:
Department of Motor Vehicles
CDL Unit, G204
P.O. Box 944278
Sacramento, CA 94244-2780
*DL694*
