Skill Performance Evaluation Certificate Application

Submit the completed SPE certificate application packet to the medical program specialist in the service center for the state in which you are a legal resident. The addresses for the service centers are as follows: Eastern Service Center: 4749 Lincoln Mall Drive, Suite 300A, Matteson, IL 60443; Phone: (708) 283-3577; FAX: (708) 283-3579. Midwestern Service Center: 1800 Century Boulevard, N.E., Suite 1700, Atlanta, GA 30345-3220; Phone: (404) 327-7371; FAX: (404) 327-7359. Southern Service Center: 1800 Century Boulevard, N.E., Suite 1700, Atlanta, GA 30345-3220; Phone: (404) 327-7371; FAX: (404) 327-7359. Western Service Center: handled by the Southern Service Center. Ensure all required documents are included to avoid delays.

There are no specific dates applicable for this form in 2024 and 2025. It can be submitted at any time when you have gathered all required information and documents.

The purpose of this form is to apply for the Skill Performance Evaluation (SPE) Certificate, which allows commercial drivers with limb impairments or amputations to legally operate vehicles. This certificate demonstrates that the applicant has met all necessary medical and driving requirements. The form collects detailed information about the applicant, their medical condition, and their driving experience to ensure they meet the qualifications for the SPE program.

• 1. Name: The full legal name of the applicant.
• 2. Date of Birth: The applicant's date of birth.
• 3. Address: The applicant's home address including city, state, and ZIP code.
• 4. Telephone #: The applicant's phone number.
• 5. Driver's License #: The applicant's driver's license number and state of issuance.
• 6. Limb Impairment Description: A description of the applicant's limb impairment or amputation.
• 7. Prosthesis Type: The type of prosthesis worn, if applicable.
• 8. Driving Experience: Details about the applicant's driving experience including vehicle types, states of operation, and time periods.
• 9. Vehicle Description: Information about the vehicle(s) operated by the applicant including make, model, year, transmission type, and other specifications.
• 10. Vehicle Modifications: A description of any modifications made to the vehicle to accommodate the applicant's impairment.
• 11. Certification: A certification statement that the applicant meets the qualifications under Part 391 of the Federal Motor Carrier Safety Regulations.

Failure to submit this form may result in the inability to obtain the Skill Performance Evaluation (SPE) Certificate, which is required for certain commercial driving activities. This could impact your employment and driving eligibility.

• Employment Impact: Without the SPE certificate, you may not be eligible for certain driving jobs.
• Driving Eligibility: You may be restricted from legally operating commercial vehicles.

• 1. SPE Certificate Application: When you need to obtain the SPE Certificate for commercial driving.
• 2. Employment Verification: When your employer needs to verify your eligibility for the SPE program.
• 3. Medical Evaluation: When a medical professional needs to complete the evaluation summary for your application.