Skill Performance Evaluation Certificate Application Form printable pdf download

SKILL PERFORMANCE EVALUATION CERTIFICATE APPLICATION

PLEASE TYPE OR PRINT CLEARLY

IDENTIFICATION OF APPLICANT

NAME:________________________________________________________ DATE OF BIRTH: ____________________________________

ADDRESS:_________________________________________________________________________________________________________

CITY:________________________________________________ STATE:_______________________________ ZIP:___________________

TELEPHONE # :___________________________________________ DRIVER S LICENSE # :_____________________________________

STATE OF ISSUANCE OF DRIVER S LICENSE # : _______________________________________________________________________

DESCRIPTION OF YOUR LIMB IMPAIRMENT OR AMPUTATION: _________________________________________________________

TYPE OF PROSTHESIS WORN, IF APPLICABLE: ________________________________________________________________________

DESCRIPTION OF OPERATION

STATES OF OPERATION:____________________________________________ TYPE OF CARGO:_______________________________

AVERAGE PERIOD OF DRIVING TIME:________________ TYPE OF OPERATION (Sleeper Team, Relay, etc.): ______________________

NUMBER OF YEARS EXPERIENCE DRIVING TYPE OF VEHICLE IN APPLICATION:__________________________________________

NUMBER OF YEARS DRIVING ALL TYPES OF VEHICLES:________________________________________________________________

DESCRIPTION OF VEHICLE(S)

VEHICLE TYPE (truck, truck tractor, bus, etc.):_________________________ IF BUS, INDICATE SEATING CAPACITY:_______________

MAKE:___________________________________ MODEL # :__________________________________ YEAR:______________________

TRANSMISSION TYPE (automatic or manual):_________________________________________ # OF FORWARD SPEEDS:_____________

IF EQUIPPED WITH AUXILIARY TRANSMISSION, INDICATE # OF FORWARD SPEEDS: _____________________________________

REAR AXLE SPEED (designate single speed, 2 speed, 3 speed):_________________________________________________________________

TYPE OF BRAKE SYSTEM:___________________________________________________________________________________________

STEERING (Manual or power assisted): ___________________________________________________________________________________

NUMBER OF SEMITRAILERS OR FULL TRAILERS TO BE TOWED AT ONE TIME: ___________________________________________

DESCRIPTION OF TRAILER(S) (van, flatbed, cargo tank, lowboy, pole, dump, etc.):________________________________________________

DESCRIPTION OF VEHICLE MODIFICATIONS: _________________________________________________________________________

I CERTIFY THAT I AM OTHERWISE QUALIFIED UNDER PART 391 (QUALIFICATION OF DRIVERS) OF THE FEDERAL MOTOR

CARRIER SAFETY REGULATIONS.

Skill Performance Evaluation Certificate Application Form