Certification of Violations/Annual Review of Driving Record

MOTOR VEHICLE DRIVER'S

Certification of Violations/Annual Review of Driving Record

COMPLETED BY DRIVER - CERTIFICATION OF VIOLATIONS
Name Of Driver: (PRINT)
Social Security Number
Date Of Employment

MonthDayYear
Date
Home Terminal (CITY AND STATE)
Driver's License Number
State
Expiration Date

MonthDayYear
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.
If you have had no violations, check the following box

None

MOTOR VEHICLE DRIVER'S