Certification of Violations and Review

COMMERCIAL MOTOR VEHICLE DRIVERS ONLY

FALSIFICATION OF THIS DOCUMENT IS GROUNDS FOR TERMINATION

 

MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver  it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27).  Drivers who have provided information required by Section  383.31 need not repeat that information on this form.

 

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above.  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 (Section 391.27).

Please fill out this form, sign below, then click submit when you are finished.

Driver's Name:		Manager's Name/Plant #:
Driver's License Number:		State:	Expiration Date:
DRIVER’S INSTRUCTIONS: List all traffic violations (other than parking violations) for which you have been convicted or forfeited bond or collateral during the past 12 months. (Note: This list should include violations involving any type vehicle whether a commercial vehicle or a personal vehicle.) Sign where indicated.
Have you had any violations within the past 12 months?     Yes No

Date of Conviction	Offense*	*If Speeding, list speed. Actual/Posted	Location	Type of Vehicle Operated
I certify that the above is a true and complete list of all traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months. I understand that falsification of this document would be grounds for termination.
Date of Certification 11/04/2025
Driver's Signature:

Please use your mouse to provide a signature. Position your mouse cursor over shaded box below Holding the left side button on mouse down Drag the mouse to create signature Release the mouse button If you need a little practice, click the "Erase" button and try again When you are done, click the "Save" button

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