MOTOR CARRIER INSTURCITONS: 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).
Social Security #
Date of Employment
Home Terminal (City & State)
Drivers License #
Drivers License State
Drivers License 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 collateral during the past 12 months.
If you have had no violations, check the following box and leave the next section blank: No Violations
If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation ( other than those I have provided under Part 383) required to be listed during the past 12 months.
Date of Submission