Annual Certification of Violations / Annual Review of Driving Record
Annual Certification of Violations / Annual Review of Driving Record for:
Driver's License Number:
State of Issue:
Driver's License Expiration Date:
Are you currently employed by any other employer at this time?
RESPONSIBILITY OF MOTOR CARRIER: EACH DRIVER MUST COMPLETE THIS CERTIFICATION ANNUALLY. INCLUDE VIOLATIONS IN A CMV AND/OR PERSONAL VEHICLE (EVEN THOSE OCCURRING OUTSIDE YOUR HOME STATE).
INSTRUCTIONS TO DRIVER: I CERTIFY THAT THE FOLLOWING IS A TRUE AND COMPLETE LIST OF TRAFFIC VIOLATIONS (OTHER THAN PARKING VIOLATIONS) FOR WHICH I HAVE BEEN CONVICTED OR FORFEITED BOND OR COLLATERAL DURING THE PAST 12 MONTHS.
Authorization: This form is for authorization to annually pull your MVR (motor vehicle record) for insurance purposes and review. This form exists in a secure environment, and the information is sent directly to the employer for review and storage in a secure environment.
Type of record that will be requested can only be:
EMPLOYMENT RECORD. Used to determine if a driver should be employed. Employers and their agents, prospective employers and their agents.
Please enter all Violations of motor vehicle laws or ordinances (other than violations involving only parking) of which the commercial driver was convicted or forfeited bond or collateral during the last 12 months preceding today's date. These will be verified with your Motor Vehicle Record.
Additionally, by signing electronically below, you authorize your employer to pull a current MVR as needed for the Annual Review of Driving Record and the Annual Certification of Violations
Please check this box to indicate whether you have had violations in the previous 12 Months:
First Violation Date of occurrence:
Nature of First Violation:
First Location or Municipality:
Was this in a Commercial Motor Vehicle?
Were Fatalities or Personal Injuries Sustained?
Second Violation Date of occurrence:
Nature of Second Violation:
Second Location or Municipality:
Third Violation Date of occurrence:
Nature of Third Violation:
Third Location or Municipality:
Fourth Date of occurrence:
Nature of Fourth Violation:
I CERTIFY THAT THE INFORMATION GIVEN ABOVE IS A TRUE AND ACCURATE STATEMENT OF MY RECORD OF MOTOR VEHICLE VIOLATIONS FOR THE PREVIOUS 12 MONTH PERIOD.
Annual Inquiry and Review of Driving Record
In accordance with 49 CFR Section 391.25, Federal Motor Carrier Safety Regulations, I have reviewed and considered:
Ο - MEETS THE MINIMUM REQUIREMENTS
Ο - IS DISQUALIFIED (SEE COMMENTS AS NECESSARY)
Reviewing Supervisor's Signature ___________________________________________
Date Signed ________________________ Position with Company ________________
Leave this empty:
Your legal name
If you have questions about the contents of this document, you can email the document owner.
Document Name: Annual Certification of Violations / Annual Review of Driving Record
Agree & Sign