Annual Certification of Violations / Annual Review of Driving Record


 

 

Annual Certification of Violations / Annual Review of Driving Record for:

 

Driver's License Number: 

State of Issue: 

Driver's License Expiration Date: 

Are you currently employed by any other employer at this time? 

Other Employer's Name:  

RESPONSIBILITY OF MOTOR CARRIER: EACH DRIVER MUST COMPLETE THIS CERTIFICATION ANNUALLY. INCLUDE VIOLATIONS IN A CMV AND/OR PERSONAL VEHICLE (EVEN THOSE OCCURRING OUTSIDE YOUR HOME STATE).

INSTRUCTIONS TO DRIVER: 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.

Please enter all Violations of motor vehicle laws or ordinances (other than violations involving only parking) of which the commercial driver was convicted or forfeited bond or collateral during the last 12 months preceding today's date. These will be verified with your Motor Vehicle Record.

Additionally, by signing electronically below, you authorize your employer to pull a current MVR as needed for the Annual Review of Driving Record and the Annual Certification of Violations.

Please check this box to indicate whether you have had violations in the previous 12 Months:

One:

First Violation Date of occurrence: 

Nature of First Violation:

First Location or Municipality: 

Was this in a Commercial Motor Vehicle? 

Were Fatalities or Personal Injuries Sustained? 

Two:

Second Violation Date of occurrence: 

Nature of Second Violation:

Second Location or Municipality: 

Was this in a Commercial Motor Vehicle? 

Were Fatalities or Personal Injuries Sustained? 

Three:

Third Violation Date of occurrence: 

Nature of Third Violation:

Third Location or Municipality: 

Was this in a Commercial Motor Vehicle? 

Were Fatalities or Personal Injuries Sustained? 

Four:

Fourth Date of occurrence: 

Nature of Fourth Violation:

Third Location or Municipality: 

Was this in a Commercial Motor Vehicle? 

Were Fatalities or Personal Injuries Sustained? 

I CERTIFY THAT THE INFORMATION GIVEN ABOVE IS A TRUE AND ACCURATE STATEMENT OF MY RECORD OF MOTOR VEHICLE VIOLATIONS FOR THE PREVIOUS 12 MONTH PERIOD.  

 

Annual Inquiry and Review of Driving Record

 

In accordance with 49 CFR Section 391.25, Federal Motor Carrier Safety Regulations, I have reviewed and considered:

  • Current MVR from every State in which the driver held a CDL or permit during the prior 12 months (attach a copy of all documents)
  • Driver's accident record and any evidence that the driver has violated laws governing the operations of motor vehicles. Great weight must be given to violations, such as speeding, reckless driving, and operating under the influence of alcohol or drugs, that indicate that the driver has exhibited a disregard for the safety of the public;
  • Any evidence the driver has violated any applicable Federal Motor Carrier Safety Regulations or Hazardous Materials Regulations (49 CFR chapter I, subchapter C); for the last 12 months, and have found that: 

 

Ο - MEETS THE MINIMUM REQUIREMENTS

Ο - IS DISQUALIFIED (SEE COMMENTS AS NECESSARY)

Reviewing Supervisor's Signature ___________________________________________

Date Signed ________________________   Position with Company ________________

Leave this empty:

Signature arrow
Windstar Lines Safety Systems https://www.gowindstarsafety.com
Signature Certificate
Document name: Annual Certification of Violations / Annual Review of Driving Record
lock iconUnique Document ID: 15fb9d1a5f150181ce15824e728a2c094a1acfd0
Timestamp Audit
October 29, 2016 8:52 pm CDTAnnual Certification of Violations / Annual Review of Driving Record Uploaded by Kevin Ertz - kevin@gowindstar.com IP 144.232.52.14
August 14, 2017 7:33 pm CDT Document owner admin@gowindstarsafety.com has handed over this document to kevin@gowindstar.com 2017-08-14 19:33:14 - 70.194.12.103
December 11, 2018 5:49 pm CDTDave Kincheloe - dave@gowindstar.com added by Kevin Ertz - kevin@gowindstar.com as a CC'd Recipient Ip: 206.222.218.153
August 27, 2019 4:09 pm CDTDave Kincheloe - dave@gowindstar.com added by Kevin Ertz - kevin@gowindstar.com as a CC'd Recipient Ip: 144.232.52.14