(CDL MedCert1 iss. 01/2017)
Kansas Commercial Driver’s License Holder – Medical Self Certification
Effective: January 30, 2012
The Kansas Division of Vehicles is collecting CDL applicants’ Medical Self Certification as Part of the CDL as
required by Federal Motor Carrier Safety Regulations, 49 CFR Part 383, 384, 390 & 391.
Part A
Name of Driver: (Print Clearly) (Last, First, Middle, Suffix)
Date of Birth: (Month) (Day) (Year)
Kansas Driver’s License or Commercial License Number:
Today’s Date: (Month) (Day) (Year)
Note: Only Class A, B, or C applicants that check the first self-certification box below must submit a copy of their
valid medical certification card. (Kansas does not require the medical certification long form). All Commercial Class
A, B, or C applicants must submit this self-certification upon original application, renewal, upgrade or transfer of a
Kansas commercial driver’s license.
The Driver’s License Agency is not responsible for determining a driver’s self-certification classification; that is the
sole responsibility of the driver. You may submit your medical card in person to a full service exam station, you may
also mail, email or fax in your medical card.
Mail: P.O. Box 2188 Topeka, KS 66601-2188. Email: kdor_medical.certification@ks.gov Fax: 785-296-5859
Part B
I certify my commercial transportation is: (Check only one of the following categories that apply to you).
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Category 1. Interstate, and I am both subject to and meet 49 CFR Part 391. (Copy of DOT medical card
and this certification must be submitted to the State Driver’s License Agency) (Complete reverse side of
this form).
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Category 2. Interstate, but operating exclusively in transportation or operations excepted under 49 CFR
390.3(f), 391.2, 391.68, or 398.3. (Only this certification must be submitted to the State Driver’s License
Agency).
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Category 3. Intrastate, and I am both subject to and meet State driver medical qualification requirements.
(Requires driver to carry medical card; however, only this certification must be submitted to the State
Driver’s License Agency). (Requires Intrastate only “K” restriction on CDL credential)
☐
Category 4. Intrastate, but operating exclusively in transportation or operations excepted from all or part
of the State driver qualification requirements. (Only this certification must be submitted to the State
Driver’s License Agency). (Requires Intrastate only “K” restriction on CDL credential)
Driver’s Signature (Required) Date (mm/dd/yy)
Daytime Phone w/Area Code:
Email address:
click to sign
signature
click to edit
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