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Get NC CDL-MED-1 2013

Signature Date 1 Scan the documents and then email them to CDLmedical ncdot. gov 2 Mail this form and copies of medical card/certificate to NCDMV CDL Medical Certification Unit 3126 Mail Service Center Raleigh NC 27699-3126 3 Fax this form and medical documents to the CDL Med. Cert Unit. CDL-MED-1 Rev. 11/13 State of North Carolina North Carolina Department of Transportation Division of Motor Vehicles MEDICAL CERTIFICATION FOR COMMERCIAL DRIVER LICENSE Name First Middle Last Suffix Social Security Number Date of Birth CHECK THE APPROPRIATE BOX FOR THE TYPE OF OPERATION THAT APPLIES TO YOU ONLY ONE BOX MAY BE CHECKED NON-EXCEPTED INTERSTATE operates or expects to operate in interstate commerce is both subject to and meets the qualification requirements under 49 CFR part 391 and is required to obtain a medical examiner s certificate by 391. 45. Required to have a DOT medical card/certificate EXCEPTED INTERSTATE operates or expects to operate in interstate commerce but engages exclusively in transportation or operations excepted under 49 CFR 390. 3 f 391. 2 391. 68 or 398. 3 from all or parts of the qualification requirements of 49 CFR part 391 and is therefore not required to obtain a medical examiner s See Medical Certification Requirements FAQ Sheet requirements. operations excepted from all or parts of the State driver qualification requirements I certify under penalty of perjury that all statements above are true and correct. Fax number is 919 861-3915 4 Deliver this form and medical documents to your local NCDMV office. A list of office locations and hours can be found on our website www. ncdot. gov/dmv Please contact the CDL Medical Certification Unit at 919 861-3599 if you have any questions regarding this form*. 45. Required to have a DOT medical card/certificate EXCEPTED INTERSTATE operates or expects to operate in interstate commerce but engages exclusively in transportation or operations excepted under 49 CFR 390. 3 f 391. 2 391. 68 or 398. 3 from all or parts of the qualification requirements of 49 CFR part 391 and is therefore not required to obtain a medical examiner s See Medical Certification Requirements FAQ Sheet requirements. 3 f 391. 2 391. 68 or 398. 3 from all or parts of the qualification requirements of 49 CFR part 391 and is therefore not required to obtain a medical examiner s See Medical Certification Requirements FAQ Sheet requirements. operations excepted from all or parts of the State driver qualification requirements I certify under penalty of perjury that all statements above are true and correct. Fax number is 919 861-3915 4 Deliver this form and medical documents to your local NCDMV office. A list of office locations and hours can be found on our website www. ncdot. gov/dmv Please contact the CDL Medical Certification Unit at 919 861-3599 if you have any questions regarding this form*. 45. Required to have a DOT medical card/certificate EXCEPTED INTERSTATE operates or expects to operate in interstate commerce but engages exclusively in transportation or operations excepted under 49 CFR 390. 3 f 391. 2 391. 68 or 398. 3 from all or parts of the qualification requirements of 49 CFR part 391 and is therefore not required to obtain a medical examiner s See Medical Certification Requirements FAQ Sheet requirements. operations excepted from all or parts of the State driver qualification requirements I certify under penalty of perjury that all statements above are true and correct. .

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