SECTION B. OR, I FURTHER CERTIFY THAT I Meet the physical qualifications of 49 CFR, Part 391, because I: (check all boxes that apply)
1. Do not have a loss of a foot, a leg, a hand, or an arm, or have been granted a Texas waiver;
2.
Do not have an impairment of:
i. A hand or nger which interferes with prehension or power grasping; or
ii. An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a motor vehicle;
or any other signicant limb defect or limitation which interferes with the ability to perform normal tasks associated with
operating a motor vehicle; or have been granted a waiver;
3.
Do not have a current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufciency, thrombosis, or any other
cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse, or congestive cardiac failure;
4.
Do not have an established medical record history or clinical diagnosis of a respiratory dysfunction likely to interfere with my
ability to control and drive a motor vehicle safely;
5.
Do not have a current clinical diagnosis of high blood pressure likely to interfere with my ability to operate a motor vehicle safely;
6.
Do not have an established medical history or clinical diagnosis of rheumatic, arthritic, orthopedic, muscular, neuromuscular, or
vascular disease which interferes with my ability to control and operate a motor vehicle safely;
7.
Do not have an established medical history or clinical diagnosis of epilepsy or any other condition which is likely to cause loss of
consciousness or any loss of ability to control a motor vehicle;
8.
Do not have a mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with my ability to drive a
motor vehicle safely;
9.
Have 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, eld of vision at least 70º in the horizontal Meridian in each eye, and the ability to recognize the colors of trafc
signals and devices showing standard red, green, and amber; or have been granted a Texas waiver;
10.
First perceive a forced whispered voice in the better ear at not less than 5 feet with or without the use of a hearing aid or, if tested
by use of an audiometric device, do not have an average hearing loss in the better ear greater than 40 decibels at 55 Hz, 1,000
Hz, and 2,000 Hz with or without a hearing aid when the audiometric device is calibrated to American National Standard (formerly
ASA Standard) Z24.5-1951;
11.
Do not use a Schedule I drug or other substance, an amphetamine, a narcotic, or any other habit forming drug; and
12.
Do not use any non-Schedule I drug or substance that is identied in the other Schedules in 21 part 1308 except when the use
is prescribed by a licensed medical practitioner, as dened in §382.107, who is familiar with the driver’s medical history and has
advised the driver that the substance will not adversely affect the driver’s ability to safely operate a commercial motor vehicle;
13.
Do not have a current clinical diagnosis of alcoholism.
IF YOU HAVE CHECKED ALL THE BOXES ABOVE, THIS IDENTIFIES THAT YOU MEET THE FEDERAL SELF-CERTIFICATION CATEGORY 3, NON-EXCEPTED
INTRASTATE (49 C.F.R. PART 383.71(b)(1)(iii)). A MEDICAL EXAMINER’S CERTIFICATE IS REQUIRED TO BE PRESENTED FOR THE ISSUANCE OF THIS CDL.
SECTION C. OR, I FURTHER CERTIFY THAT I: (CHECK THE APPROPRIATE BOX(ES) IF APPLICABLE)
YES NO Am exempt from the physical provisions of 49 CFR, Part 391/390 as I will operate a commercial motor vehicle only in the
following capacity.
1.
The operation of a vehicle operated intrastate and used in oil or water well servicing or oil or water well drilling and which is
constructed as a machine consisting, in general, of a mast, an engine for power, a draw works, and a chassis permanently
constructed or assembled for such purpose.
2.
The operation of a mobile crane that is an unladen self-propelled vehicle constructed as a machine used to raise, shift, or
lower weights.
IF YOU HAVE SELECTED YES FOR SECTION C, YOU MEET THE FEDERAL SELF-CERTIFICATION CATEGORY 4, EXCEPTED INTRASTATE (49 C.F.R. PART 383.71(b)
(1)(iv)). A MEDICAL EXAMINER’S CERTIFICATE IS NOT REQUIRED TO BE PRESENTED FOR THE ISSUANCE OF THIS CDL.
I CERTIFY THAT I OPERATE OR EXPECT TO OPERATE A COMMERCIAL MOTOR VEHICLE IN INTRASTATE COMMERCE ONLY. I ENGAGE OR WILL ENGAGE
EXCLUSIVELY IN TRANSPORTATION OR OPERATIONS AND I AM SUBJECT TO THE PHYSICAL QUALIFICATIONS OF 49 C.F.R. PART 391. I FURTHER CERTIFY
THAT I HAVE READ, UNDERSTAND, AND MEET THE PRECEDING QUALIFICATIONS.
FOR DEPARTMENT USE ONLY
Intrastate restriction must be placed on the license. Optional Y – Valid Texas vision or limb waiver required
Section C, Box 1 requires P25 – if cmv, use in oil/water well serv/drill Medical Examiner’s certificate is required if Section B is selected.
Section C, Box 2 requires P26 – if cmv, for operation of mobile crane Class C - General Knowledge and any necessary endorsement exams.
Class A - Texas Commercial Rules, General Knowledge, Combination, Air-brake (if applicable), Pre-trip, and any necessary endorsement exams.
Class B - Texas Commercial Rules, General Knowledge, Air-brake (if applicable), Pre-trip, and any necessary endorsement exams.
Skills exams required: Yes
I CERTIFY THAT I OPERATE OR EXPECT TO OPERATE A COMMERCIAL MOTOR VEHICLE IN INTRASTATE COMMERCE ONLY. I ENGAGE OR WILL ENGAGE
EXCLUSIVELY IN TRANSPORTATION OR OPERATIONS THAT EXEMPT ME FROM BEING REQUIRED TO MEET THE MEDICAL STANDARDS OF 49 C.F.R. PART 391.
I FURTHER CERTIFY THAT I HAVE READ, UNDERSTAND, AND MEET THE PRECEDING QUALIFICATIONS.
APPLICANT’S SIGNATURE DATE
Sworn to and subscribed before me on this the day of ,
Notary Public or Authorized Officer
APPLICANT’S SIGNATURE DATE
