Form Dl 939 - 10 Year History Record Check

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10Y
STATE OF CALIFORNIA
10 YEAR HISTORY RECORD CHECK
®
DEPARTMENT OF MOTOR VEHICLES
A Public Service Agency
Complete this form if you are applying for or renewing a commercial driver license and you have been issued a driver license in
the same or different name to operate any type of motor vehicle in another state or other jurisdiction during the previous ten years.
A. PLEASE PROVIDE THE FOLLOWING:
(Name as shown on the Commercial Driver License Application DL 44C or Renewal Application)
CA DRIVER LICENSE NUMBER
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
B. OTHER STATE/JURISDICTION DRIVER LICENSE INFORMATION
For each license issued, complete all sections (even if same.)
1. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
2. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
3. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
4. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
5. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
6. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
7. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
8. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
9. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
10. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
11. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
12. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
13. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
14. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
15. STATE/COUNTRY OF ISSUANCE
DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (MM/DD/YY)
NAME (FIRST, MIDDLE, LAST, SUFFIX (JR., SR., III)
SEX
Male
Female
C. ACKNOWLEDGEMENT AND CERTIFICATION STATEMENT
I the undersigned, understand that if it is determined that the information provided has been falsified, the State may suspend,
cancel, revoke my commercial driver license, or pending application, or disqualify me from operating a commercial motor vehicle
for a period of at least 60 consecutive days. I certify (or declare) under penalty of perjury under the laws of the State of
California that the foregoing is true and correct.
SIGNATURE
DATE
X
DL 939 (REV. 11/2010) WWW
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