Name (Last, First, M.I.)___________________ (Soc. Sec. No.)______________
This day I reviewed the driving record of the above named driver in accordance with 391.25 of the Federal Motor Carrier Safety Regulations. I considered any evidence that the driver has violated applicable provisions of the Federal Motor Carrier Safety Regulations and the Hazardous Materials Regulations. I considered the driver’s accident record and any evidence that he/she violated laws governing the operation of motor vehicles, and gave great weight to violations, such as speeding, reckless driving and operation while under the influence of alcohol or drugs, that indicate that the driver has exhibited a disregard for the safety of the public. Having done the above, I find that:
_ the driver meets the minimum requirements for safe driving, or
_ the driver is disqualified to drive a motor vehicle pursuant to 391.15
Date of Review__________________ Motor Carrier’s Name_________________
Reviewed
by: Signature and title ______________________________________
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Date of Review __________________Motor Carrier’s Name ________________
Reviewed
by: Signature and title ______________________________________
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Date of Review __________________Motor Carrier’s Name ________________
Reviewed by: Signature and title ______________________________________