Certification of Violations / Annual Review of Driving Record

COMPLETED BY DRIVER - DRIVER INFORMATION

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier below. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section391.27)

First Name:*
Last Name:*
Date of Birth:*
License Number:*
License State:*
License Exp. Date:*

COMPLETED BY DRIVER - VIOLATION SECTION

List all violations you have had in the last 12 months below.

Violation 1:

Date:
Offense:
Location:
Type of Vehicle Operated:

Violation 2:

Date:
Offense
Location
Type of Vehicle Operated:

Violation 3:

Date:
Offense:
Location:
Type of Vehicle Operated:

Violation 4:

Date:
Offense:
Location:
Type of Vehicle Operated:

COMPLETED BY DRIVER - CERTIFICATION

I certify that the above is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months. If all the boxes above are empty, I understand that I am certifing that I have had no violations in the last 12 months.

My signature below authorizes the company or its agent to order my motor vehicle record to complete this process.

Please sign below
Sign above