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Kansas Commercial Driver's License Holder Medical Self Certification
The Kansas Division of Vehicles is collecting medical self-certifications for all Kansas CDL holders as required by the Federal Motor Carrier Safety Regulations, 49 CFR Part 383, 384, 390 & 391. In addition to completing this electronic form, if you are subject to presenting your DOT medical card it must be uploaded at the end of this transaction or faxed into our department. Fax: 785-296-5859
Date of Birth
Kansas driver's license or commercial license number
(With no dashes or spaces)
Category 1. Interstate, and I am both subject to and meet 49 CFR Part 391. A copy of DOT medical card and this certification must be submitted to the state driver licensing agency.
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 licensing agency.
Category 3. Intrastate, and I am both subject to and meet state driver medical qualification requirements. This requires the driver to carry a medical card; however, only this certification must be submitted to the state driver licensing agency. Requires Intrastate only "K" restriction on CDL credential.
Category 4. Intrastate, but operating exclusively in transportation or operations excepted from all or parts of the state driver qualification requirements. Only this certification must be submitted to the state driver licensing agency. Requires Intrastate only "K" restriction on CDL credential.
(Do Not Enter Dashes ex: 9999999999)
Medical Examiner's First Name
Medical Examiner's Middle Name
Medical Examiner's Last Name
Medical Examiner's Suffix
Medical Examiner's License Number
Medical Examiner's Registry Number
Medical Examiner's Phone Number
Exam Date (MM/DD/YYYY)
Medical Examiner's Specialty
Advance Practice Nurse
Medical Certificate Issue Date (MM/DD/YYYY)
Medical Certificate Expiration Date (MM/DD/YYYY)
Qualified under CFR 391.64
Driving Exempt under CFR 391.62
Accompanied by SPE
Please Go to the nearest Driver's License Evaluation Center to complete this Application.
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