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Get massDOT Form T21893 2012

Ision of MassDOT of the type of commerce in which they operate (interstate or intrastate), and whether or not they are required to hold a medical certificate. Failure to provide this information, known as self-certifying, prior to January 30, 2014 will result in the loss of the holder’s CDL. COMMERCIAL DRIVER INFORMATION DRIVER NAME (print) (last) ADDRESS (street) LICENSE/PERMIT NUMBER (first) (middle) (city) DAYTIME TELEPHONE NUMBER ( ) (state) BIRTHDATE (mm/dd/yyyy) (zip code) EMAI.

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