MOTOR VEHICLE DRIVER’S CERTIFICATION OF VIOLATIONS

 

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.

 

Date	Offense	Location	Type of Vehicle Operated
______________  ______________  ______________  ______________  ______________	______________  ______________  ______________  ______________  ______________	______________  ______________  ______________  ______________  ______________	______________  ______________  ______________  ______________  ______________

 

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months.

 

(Date of Certification)_____________________________

(Driver’s Signature) ______________________________

(Motor Carrier’s Name) ___________________________

(Motor Carrier’s Address)_________________________

(Reviewed by: Signature)_________________________

(Title)_________________________________________