Alaska CDL MEDICAL SELF CERTIFICATION Application PDF (form 413 pdf)

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(Rev . 6 /202 3 ) Alaska.gov/dmv STATE OF ALASKA DIVISI ON OF M OTOR VE HIC LES COMME RC IAL DRIVER M ED ICAL & SELF CERTIFYING VERIFICAT ION THIS SECTI ON MUST BE C OM PLETED IN FULL BY THE APPLICA NT. MUST BE C OM PLETED IN BL ACK OR B LUE INK. FULL LEGAL NAME: First Middle Last Suffix AK license / permit / ID number, if applicable. Date of Birth E - Mail Address Phone 1. Do you meet all the requirements contained in the federal government regulations shown on the back of this form?  YES  NO List each requirement you do not meet: (Example: age 19) 2. Are you required to have a federal or state waiver to meet the medical requirements for a Commercial Driver License? (Insulin, vision or skills performance evaluation certificate) If you answered YES, you must provide a copy of the waiver.  YES  NO 3. Are you domiciled (permanent residence) in the State of Alaska?  YES  NO PLEAS E CHECK THE A PPR OPR IA TE BO X F OR TH E T YPE OF O PERAT ION THAT A PPLIE S TO YOU . SEE TH E BAC K OF T HIS F ORM FOR GU IDANCE AN D DE FINIT IONS :  NON- EX CEPTED INTERSTATE ( NI) A t ype of o perat ion t hat does not fall un de r the ex cep ted types of operat ion (Cu rrent m ed ical certific ate required. ) AND onl y ope rates in interst ate commerce (see reverse for mo re infor ma tion).  NON- EX CEPTED IN TR ASTATE ( NA ) A t ype of o perat ion t hat does not fall un de r the ex cep ted types of operat ion (Cu rrent m ed ical certific ate required.) AND onl y ope rates in intr astate commerce (see reverse for mo re infor ma tion).  EXCEPTED INTERSTATE (E I) A t ype of o perat ion t hat falls u nder t he ex cepted ty pes of operation (M ed ical certificate NOT re qu ir ed .) AND onl y ope r ates in interst ate commerce (see reve rse for mo re infor ma tion).  EXCEPTED INTR ASTATE (EA) A t ype of o perat ion t hat falls u nder t he ex cepted ty pes of operation (M ed ical certificate NOT re qu ir ed .) AND onl y ope rates in intr astate commerce (see reverse for mo re infor ma tion). IF YOU HAVE SELECTED NON- EX CEPTE D INTERSTATE OR NON-EXC EPTED INTR ASTATE, YOU MUST PROVID E A C UR RE NT ME DICAL CERTIFICATE TO T HE DMV. DMV WILL RETA IN A COPY FO R ITS RECORDS. YOU AR E STILL REQ UIR ED TO HAVE A CURRE NT ME DICAL CERTIFICATE IN YO UR POSSESSION WHEN OPERATI NG A C OMME RC IAL MOTOR VEHIC LE. I have personally reviewed the information on this application and certify under penalty of perjury that to the best of my knowledge and belief the information on this application is true and correct. (NOTE: Making a false statement or omitting a material fact is subject to a maximum penalty of $10,000 or 1 year imprisonment or both per AS 11.56.210 and AS 28.35.135.) X_______________ _____________________________________________________________________ Signature of Applicant Date I NS T RU C T IO N S F O R S UB MI TT I N G T H I S F O R M: If y ou are applyi ng f or an origi nal, dupli ca te or renewa l of y our Co mm erci al Driv er Li cense ( CDL) , please take al l requir ed forms to y our l ocal DMV. If y our CDL is cu rrent , you m ay su bmi t the for m a long with any ot her docum ents tha t apply to y ou (Medi cal Exami ner’s Ce rtifi ca te , State or Feder al Waiver, Sk ills Perform ance Eval uati on) in t he fo llowi ng man ner: • Mai l to t he addr es s list ed below; • Scan and emai l to doa.dmv. cdl @al aska.gov; • Deliv er to y our local DM V Office. A list o f offi ce l oca ti ons and hours can be f ound on t he DM V’s w ebs it e. Your DM V record w ill be updat ed with y our cu rren t medi cal informati on withi n 10 business days fro m the date of r ece ipt . Anc horage Driver Services 4001 Ingra Street , S ui te 101 Anc horage, AK 99503 413 (Rev 6 /202 3 ) Alaska.gov/dmv CDL Me dical & Se lf Certifyin g Ve rifi cat ion Guide SPECIAL NOTE: By selecting an INTRASTA TE operation t ype , yo u are s ubject to the K res tri ct ion on you r CDL . On ly sel ect INTRASTA TE if you do not mee t the F ederal requ irement s for a CDL (under 21 o r blind in one e ye) . There are two di fferen ces betw een exc epted and non-exc epted t yp es of opera ti on. T he exc epte d types of operation are defi ned in 49 CF R 390 .3 (f). If you operate a co mmer cial moto r veh ic le (CMV) fo r any of the activiti es li st ed below a m edical c ertificate is not requi red . You w ill nee d to se lf-certify t o eit her exc epted inter st ate o r exc epte d intra st at e. • Cu st o m Farm O pera tions • Bee K eepers • Federal, State, M unici pal or B orough t ran sportation and/or operati on • Occ a si onal t ran sport o f per sona l p roper ty • Tran spor tation of human c orp se s or sick/inj ure d per sons • Fire trucks and res cue veh icles • CMVs use d to t rans por t bet ween 9 and 15 pas sengers , incl uding the dri ver • CMVs use d prim arily in t ran spo rtatio n of propane winte r hea ting f uel • Drive r of m igrant work ers If you operate a CMV outside o f the exc epted t ype s of operation, yo u are consi dered non -exc ept ed, and are requ ired to hav e a valid medical exa miner s certificate. Difference betwee n interstate a nd intr as tat e In terstat e = If the vehicle o r load ( ma y be go od s or pa sseng ers) Intr astat e = If the v ehicle or load ( ma y be goods o r passenger s) origi nat es origi nates in one state and is t ranspor ted to or thro ugh a nother state, in Alaska and the o perator does not transp ort the v ehic le or l oad the opera tion wou ld be consid ered “in terstate co mmer ce.” ou tsi de of Alaska, it is conside red “intrasta te co mmer ce.” If yo u hav e any que st ions regardin g the se lf-c ertification t ype s or the requi rement s, pl ease c ont act An chorage Drive r Services at (907 ) 269-3770 o r via Ema il a t DOA.DM V.ADS@Alask a.go v fo r assi st ance prior to submi tting the form. DE FINITIONS Domicile: "domicile" means the true and permanent home of a person from which the person has no present intention of moving and to which the person intends to return whenever the person is away. INTERSTA TE C OMM ERCE mean s trade , traffic, or t ran spor tation in the Un ited States— (1) Betw een a place in a State and a place out side o f such State (i ncludin g a place out side o f the Un ited States); (2) Betw een two place s in a State t hrough ano ther State or a place outs ide o f th e Un ited States ; or (3) Betw een two place s in a State a s part o f trade , traf fic, or t ran spor tation origi nating or terminating out side the Stat e or the Un ited States. Example : If the veh ic le o r load origi nate s in one state and is trans ported to or t hrough ano ther st at e, the operation w ould be consi dered “int erst at e commerc e”. INTRA ST ATE C OMM ERC E means any t rade , traffic, or t ran sportatio n in any State which is not des cribed in the term "int ers tate co mmerce” . Example : If the veh ic le o r load origi nate s in one state and operato r does not trans por t the veh ic le o r loa d outside o f the origi nal st at e, it is c onsi dered “int rast ate commerce ”. COMM ERC E mean s (a) any trad e, tra ffic or t ran sportation with in the j urisdi ct ion o f the Un ited States betw een a place in a State and a place out side o f suc h State, incl uding a place out side o f the Un ited States and (b) t rade , tra ffic , and t rans por tation in the Un ited State s which affects any trade, t raffic , and tran sportation des cri bed in paragraph (a) of th is definiti on. 49 CFR 383.7 1 DRIVER APPLICA TI ON A ND CERTIFI CA TI ON P RO CEDURES. NON- EXC EPTED INTERSTATE . A person mus t cert ify t hat he or she operates or ex pects to operate in int ers tate co mmerce , is both subjec t to and meet s the qua lification requirement s unde r 49 CFR par t 391, and is r equ ired to obta in a m edical exami ner ’s cert ifi cate b y 391.45 o f thi s chap ter. EXCEPTED INTERSTATE . A per son mus t certif y that he or sh e ope rates o r ex pect s to operate in int erst ate commerce , but engages exclusi ve ly in tran sportation o r opera tions exc epted under 49 C FR 390 .3(f) , 391 .2, 391.68 o r 398 .3 from a ll part s of the qualification requ irem ent s of 49 C FR par t 391 , and i s there fore not requ ired to obta in a m edical exa miner ’s cert ificat e by 49 C FR 391.45 o f thi s ch apt er. NON- EX C EPTE D INTRA ST ATE . A person mus t cert ify t hat he or she operate s in int rast ate co mmer ce and t here fore is subjec t to State driv er qualification requirements. EXCEPTED INTRA ST ATE . A per son mus t certif y that he or she ope rates in intra st ate co mmer ce , but engages exclusi ve ly in t ran sportation or operati ons exc epted from a ll o r parts o f the State dri ve r qua lification requ irement s. 49 CFR Part 391.11 GENERAL QUALIFICATIONS OF DRIVERS. (a) A person shall not drive a commercial motor vehicle unless he/she is qualified to drive a commercial motor vehicle. Except as provided in 391.63 , a motor carrier shall not require or permit a person to drive a commercial motor vehicle unless that person is qualified to drive a commercial motor ve hicle. (b) Except as provided in subpart G of this part, a person is qualified to drive a commercial motor vehicle if he/she – (1) Is at least 21 years old; (2) Can read and speak the English language sufficiently to converse with the general public, to understand highway traffic signs and signals in the English language, to respond to official inquiries, and to make entries on reports and records; (3) Can, by reason of experience, training, or both, safely operate the type of commercial motor vehicle he/she drives; (4) Is physically qualified to drive a commercial motor vehicle in accordance with subpart E -- Physical Qualifications and Examinations of this part; (5) Has a currently valid commercial motor vehicle operator's license issued only by one State or jurisdiction; (6) Has prepared and furnished the motor carrier that employs him/her with the list of violations or the certificate as required by 391.27 . (7) Is not disqualified to drive a commercial motor vehicle under the rules in 391.15; and (8) Has successfully completed a driver's road test and has been issued a certificate of driver's road test in accordance with 391.31 , or has presented an operator's license or a certificate of road test which the motor carrier that employs him/her has accepted as equivalent to a road test in accordance with 391.33. REQUIRED TESTS Both the Alaska and the CDL General Knowledge tests or equivalent are required to obtain a permit or license. You must pass the air brakes knowledge test or an “L” restriction will be added to the license or permit. You would be restricted to operating vehicles not equipped with air brakes. Class A and IA require the combination knowledge test.