Fillable Special Certificate Application, Chp 295 - California Highway Patrol printable pdf download

STATE OF CALIFORNIA

DEPARTMENT OF CALIFORNIA HIGHWAY PATROL

CERTIFICATE TYPE

SPECIAL CERTIFICATE APPLICATION

School Bus

Youth Bus

SPAB

Original

Renewal

Duplicate

CHP 295 (Rev. 2-14) OPI 061

Farm Labor

GPPV

VDDP

Upgrade

Downgrade

Information on this form pertains to the issuance of a certificate to operate

office hours. By law, the information from this form is transferred to the

a motor vehicle under Division 6 of the California Vehicle Code. Failure to

Department of Motor Vehicles (DMV), Commercial Driver License Unit,

provide information or providing false information on this and/or

P.O. Box 944278, Sacramento, CA 94290-0001, telephone (916) 657-5771,

associated forms is cause for refusal, suspension, or revocation of the

and it is maintained as part of your driving record. This form and related

certificate sought.

documents are maintained by the California Highway Patrol (CHP) office where

Except as made confidential by law or exempted under the Freedom of

you applied and tested for the certificate, or the CHP office in the area where

Information Act, this information is a public record. It is regularly used by

you work.

law enforcement agencies, other state agencies, and insurance

Your Social Security Number (SSN) is required to ensure positive identification

companies, and it is open to inspection by the public. You are entitled to

for the personal background check required by the California Vehicle Code.

inspect or obtain copies of information in your record during regular

PLEASE PRINT CAREFULLY

NAME (FIRST, MIDDLE, LAST)

SOCIAL SECURITY NUMBER

HOME TELEPHONE NUMBER

HOME ADDRESS (NUMBER AND STREET)

CITY

ZIP CODE

EMPLOYER

WORK TELEPHONE NUMBER

EMPLOYER'S ADDRESS (NUMBER AND STREET)

CITY

ZIP CODE

CHP OFFICE WHERE YOU LAST APPLIED FOR A CERTIFICATE

PLACE OF BIRTH (CITY AND STATE)

DRIVER LICENSE INFORMATION

SEX

HAIR

EYES

HEIGHT

WEIGHT

RESTRICTIONS

DATE OF BIRTH (MONTH, DAY, YEAR)

STATE

NUMBER

CLASS

ENDORSEMENTS

EXPIRES

CORRECTIVE LENSES REQUIRED

MEDICAL CARD EXPIRES

YES

CHP USE ONLY

FINGERPRINTS

DATE SENT TO:

DOJ

FBI

ATI#

DATE RETURNED:

DOJ

FBI

MARK AN X IN THE APPROPRIATE PASS/FAIL BOX FOR EACH TEST TAKEN.

TESTS

RULES AND REGULATIONS

FIRST AID

DATE

TEST

ANSWERS MISSED

DATE

TEST

ANSWERS MISSED

CERTIFICATE INFORMATION

ISSUE DATE (SHOULD BE SAME AS ON THE DL45)

DATE FILE SENT FOR DMV REVIEW

RESTRICTIONS

APPLICANT FOR A SCHOOL BUS, SPAB, FLV, YOUTH BUS, GPPV, OR VDDP CERTIFICATE

(ACCIDENT INCIDENT DATA - ATTACH ADDITIONAL PAGE IF NEEDED).

NONE

DRIVER LICENSE AND CERTIFICATE - 12517(a), 12519(a), 12523(a), 12523.5(a),

AUTOMATIC TRANSMISSION ONLY

12523.6(a) VC

HYDRAULIC BRAKES ONLY

TRAINING REQUIREMENTS VERIFICATION DATE:

TYPE 2 BUS ONLY

MEDICAL - MEDICAL EXAMINER'S CERTIFICATE, 12517.2 CVC

CONVENTIONAL OR TYPE 2 BUS ONLY

LICENSING ELIGIBILITY DOCUMENT (Permit or Temporary License)

TWO-AXLE MOTOR TRUCK OR PASSENGER VEHICLE ONLY

WRITTEN TEST - 12517.4 VC

FIRST AID TEST WAIVED

FIRST AID TEST - 12522 VC (SCHOOL/YOUTH BUS ONLY)

ENDORSEMENT

DRIVE TEST - 12517.4 VC

MAY DRIVE VEHICLE WITH TWO-SPEED REAR AXLE

FINGERPRINTS - 12517.3(a)(1) VC

MAY TRANSPORT FROM PLACE OF RESIDENCE (YOUTH BUS ONLY)

FIRST AID CARD ISSUE DATE:

DL-45 SC NUMBER

CHP EMPLOYEE'S SIGNATURE

AREA

DATE OF APPLICATION

DATE

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Special Certificate Application, Chp 295 - California Highway Patrol

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