Fillable Intrastate CDL Disability Waiver or Hazardous Materials Variance (Virginia Department of Motor Vehicles)

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Intrastate CDL Disability Waiver or Hazardous Materials Variance (Virginia Department of Motor Vehicles)

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The Intrastate CDL Disability Waiver or Hazardous Materials Variance (Virginia Department of Motor Vehicles) form is 3 pages long and contains:

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EMPLOYMENT DATE (mm/dd/yyyy)
to
DRIVER JOB DUTIES
EMPLOYMENT INFORMATION
TYPE OF HAZARDOUS MATERIALS
TYPE OF FREIGHT
COMMODITY TO BE TRANSPORTED (check all that apply)
YEARS OF EXPERIENCE HAULING
HAZARDOUS MATERIALS
General Freight Property Passengers Hazardous Materials (Complete 3 boxes below)
EMPLOYER INFORMATION
COMPANY NAME
CARRIER SCC/ID NUMBER OR U.S. DOT NUMBER
TELEPHONE NUMBER FAX NUMBER
AUTHORIZED REPRESENTATIVE NAME (print)
ZIP CODESTATECITY
BUSINESS ADDRESS
ZIP CODE
If you change either your residence address or mailing address to a non-Virginia address, your CDL driver's license or identification (ID) card may be canceled.
DAYTIME TELEPHONE NUMBER
APPLICANT DRIVER INFORMATION
FULL LEGAL NAME (last) (first) (middle) (suffix)
SOCIAL SECURITY NUMBER OR DRIVER LICENSE NUMBER
RESIDENCE ADDRESS CITY STATE
CHECK HERE IF THIS IS A NEW ADDRESS
DATE OF BIRTH (mm/dd/yyyy)
ZIP CODE
MAILING ADDRESS
CITY STATE
CHECK HERE IF THIS IS A NEW ADDRESS
APPLICATION TYPE
Check one
New Application
Renewal Application
disabilities (3) & (10) only
Will your commercial motor vehicle (cmv) operation transport hazardous materials?
If YES - a Hazardous Materials Variance may be issued to authorize you to transport hazardous materials,
general freight and property.
If NO - a Disability Waiver may be issued to authorize you to transport general freight, property or passengers.
NOYES
I understand that if granted a waiver or variance, it would be valid only in Virginia for transporting intrastate freight, property or passengers
and therefore I certify that my CMV operations will be:
This self certification is based upon the qualification requirements under Title 19 30-20-150 of the VA Administrative Code.
EA - Excepted Intrastate NA - Non-excepted Intrastate
EI - Excepted Interstate
DISABILITY TYPES (Check type of disability for which you are applying for a waiver/variance)
(3) Have a history or clinical diagnosis of diabetes mellitus currently
requiring insulin for control (see note above).
(8) Have an established medical history of seizure or a clinical
diagnosis of epilepsy
(10) Do not have distant visual acuity or horizontal vision - with or
without corrective lenses - that meets FMCSA CDL
requirements.
Intrastate CDL Disability Waiver or Hazardous
Materials Variance Application
Purpose: Use this form to apply for a CDL (Commercial Driver's License) disability waiver or hazardous materials variance. NEW or
RENEWAL waivers or variances are granted for disabilities (1), (2), (3), (8) and (10) listed in Federal Motor Carrier Safety
Regulations FMCSA 49 C.F.R. Section (b) 391.41. To apply for a new waiver or variance for disabilities (1) and (2) use
CSL Skill Performance Evaluation Certificate Application (MED 13).
Instructions: If you have disability (8) complete this form and submit with a Customer Medical Report (MED 2) completed by your
medical provider. If you have disability (10) complete this form and submit with a Customer Vision Report (MED 4)
completed by your eye care professional. Send all completed forms to Medical Review Services at the above address. If
you have questions about completing this form, call Medical Review Services (804) 367-6203.
EI and EA drivers with disability (3) complete this form and submit with a Customer Medical Report (MED 2) completed by
your medical provider and Customer Vision Report (MED 4) completed by your eye care professional.
Note: NA drivers with disability (3) should submit a copy of the completed DOT long form (MCSA 5875), a copy of the
signed DOT Examiners Certificate (MCSA 5876), and a copy of Form 5870 (completed by the Medical Examiner). These
forms should be submitted in lieu of the Med 2 and Med 30.
Valid in Virginia ONLY
for Transporting Intrastate Freight, Property or Passengers.
MED 30 (01/25/2019)
( )
( )
( )
Does the driver meet the vision requirements listed below? .................................................................................
Does the applicant have any visual defects, condition or field loss that would affect the safe operation of a commercial
motor vehicle? ............................................................................................................................................
Is the driver able to distinguish between red, green and amber colors? ...................................................................
Federal Motor Carrier Safety Regulations FMCSA 49 C.F.R. Section (b)(10) 391.41 requires distant visual acuity of at least 20/40 (Snellen) in each eye
without corrective lenses or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least
20/40 (Snellen) in both eyes with or without corrective lenses, field of vision of at least 70 degrees in the horizontal meridian in each eye, and the ability to
recognize the colors of traffic signals and devices showing standard red, green, and amber.
Does the applicant have diabetes or any other metabolic condition(s) that might affect operation of a commercial
motor vehicle? ............................................................................................................................................
If YES, also complete applicable sections of Customer Medical Report (MED 2) and answer the questions below.
Has the driver had recurrent (two or more) hypoglycemic reactions resulting in loss of consciousness or
seizure in the last 5 years or one episode in the last 12 months? ..........................................................................
Has the driver had a recurrent (two or more) hypoglycemic reactions requiring the assistance of another
person within the past five years or one episode within the last 12 months?.............................................................
Has the driver had recurrent (two or more) hypoglycemic reactions resulting in impaired cognitive function in the
past 5 years or one episode in the last 12 months?.............................................................................................
Has the driver demonstrated willingness to monitor and manage his/her diabetes? ..................
.................................
Is the driver likely to suffer any diminution of driving ability due to his/her diabetic condition?.......................................
Drivers seeking an insulin waiver must also submit a MED 4 and the driver agreement.
DISABILITY (3) - (This section to be completed by endocrinologist)
YES NO
DISABILITY (10) - (This section to be completed by ophthalmologist/optometrist)
DMV CUSTOMER NUMBER (as it appears on license
APPLICANT NAME
YES NO
Does this applicant have a documented history of seizure or a clinical diagnosis of epilepsy?......................................
If YES, also complete Customer Medical Report (MED 2) and answer the questions below.
If the driver has a diagnosis of epilepsy, has he/she been seizure free for 8 years? ...................................................
If the driver experienced a single unprovoked seizure has he/she been seizure free for 4 years? .................................
If the driver is taking anti convulsants medications, have they been stable, or unchanged for 2 years? ..........................
If the driver experienced a single provoked seizure, address the cause on the MED 2.
DISABILITY (8) - (This section is to be completed by neurologist)
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES
NO
YES NO
YES NO
YES NO
I/We certify that the applicant is otherwise qualified pursuant to the Federal Motor Carrier Safety Regulations with the exception of the physical
disability(ies) described in this application and if I/we are applying for a Variance I/we certify that I/we understand that the law requires me/us to notify DMV
upon any change in employment.
I/we further certify and affirm that all information presented in this form is true and correct, that any documents I/we have presented to DMV are genuine,
and that the information included in all supporting documentation is true and accurate. I/we make this certification and affirmation under penalty of perjury
and I/we understand that knowingly making a false statement or representation on this form is a criminal violation.
APPLICANT DRIVER AND CARRIER/COMPANY CERTIFICATION
DRIVER SIGNATURE DATE (mm/dd/yyyy)
DATE (mm/dd/yyyy)CARRIER/COMPANY AUTHORIZED REPRESENTATIVE SIGNATURECARRIER/COMPANY AUTHORIZED REPRESENTATIVE NAME (print)
DRIVER NAME (print)
YES NO
MED 30 (01/25/2019) -- Page 2 of 3
DMV CUSTOMER NUMBER (as it appears on license
APPLICANT NAME
MEDICAL PROVIDER CERTIFICATION
MEDICAL PROVIDER NAME (print)
MEDICAL LICENSE NUMBER EXPIRATION DATE (mm/dd/yyyy)STATE ISSUING MEDICAL LICENSE
BUSINESS ADDRESS
ZIP CODESTATE
FAX NUMBER TELEPHONE NUMBER
CITY
MEDICAL PROVIDER SIGNATURE
CHECK BOX THAT APPLIES:
OPHTHALMOLOGIST PHYSICIAN NURSE PRACTITIONER
Based on my examination, this applicant is capable of safely operating a commercial motor vehicle - which includes operating tractor trailers, passenger
buses, tank vehicles, school buses for 16 or more occupants (including the driver), or vehicles carrying hazardous materials.
I further certify and affirm that to the best of my knowledge and belief, all information I have presented in this form is true and correct, that any documents I
have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and
affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
OPTOMETRIST PHYSICIAN ASSISTANT
DATE (mm/dd/yyyy)
VIRGINIA DMV DIABETES WAIVER DRIVER AGREEMENT
Read and initial applicable statements. Sign and date at the bottom of section.
INITIAL
I agree to carry a source of rapidly absorbable glucose at all times while driving.
INITIAL
I agree to self-monitor blood glucose levels prior to driving and every 2 - 4 hours while driving, using a portable monitoring device
equipped with a computerized memory.
INITIAL
I agree to submit blood glucose logs to the endocrinologist and to DMV at least annually.
For non-excepted intrastate drivers:
INITIAL
I agree to supply the endocrinologist report and blood sugar logs to the medical examiner annually or when otherwise directed to by an
authorized agent of the FMCSA.
DRIVER NAME (print) DRIVER SIGNATURE DATE (mm/dd/yyyy)
MED 30 (01/25/2019) -- Page 3 of 3
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Intrastate CDL Disability Waiver or Hazardous Materials Variance (Virginia Department of Motor Vehicles)

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Completed 29 July 2020

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