HOURS-OF-SERVICE RECORD FOR FIRST TIME OR INTERMITTENT DRIVERS

 

Instructions: When using a driver for the first time or intermittently, a signed statement must be obtained, giving the total time on duty (driving and on duty) during the immediate preceding seven days and the time at which the driver was last relieved from duty prior to beginning work.

 

Name: _____________________________________
          (print)  First        Middle        Last

 

DAY                TOTAL TIME ON DUTY

1                    ___________________

2                    ___________________

3                    ___________________

4                    ___________________

5                    ___________________

6                    ___________________

7                    ___________________

 

TOTAL            ___________________

 

I hereby certify that the information contained herein is true to the best of my knowledge and belief, and that my last period of release from duty was from (Hour/Date)____________ to (Hour/Date)_________________.

 

Signature:____________________________ Date:_________________