• MOTOR VEHICLE DRIVER'S

    Certification of Violations/Annual Review of Driving Record
  • Image field 1

  • COMPLETED BY DRIVER - CERTIFICATION OF VIOLATIONS

  • Date Of Employment
     / /
  • Expiration Date
     / /

  • I certify that the following 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 collareral during the past 12 months.

  • Offense 1

  • Date
     - -
  • Add Offense?

  • Offense 2

  • Date
     - -
  • Add Offense?

  • Offense 3

  • Date
     - -
  • Add Offense?

  • Offense 4

  • Date
     - -
  • Add Offense?

  • Offense 5

  • Date
     - -
  • Date of Certification
     / /
  •  
  • Should be Empty: