Application For Government Vehicle Operator S Permit (11240)

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APPLICATION FOR GOVERNMENT VEHICLE OPERATOR'S PERMIT (11240)
NAVMC 10964 (
REV. 2-96) (EF) (Previous editions are obsolete)
(Supersedes NAVFAC FORM 9-11240/10 FOR USMC use.)
PART I APPLICATION
2.
RANK
1. NAME (Last, First, Middle)
3.
SSN
4.
ORGANIZATION
8.
EYE COLOR
9.
HAIR
COLOR
11. DOB
10. PLACE OF BIRTH
5.
SEX
6.
HEIGHT
7.
WEIGHT
PAST DRIVING RECORD
15.
EXP. DATE
13. LICENSE NUMBER
14. ISSUE DATE
16. CLASS OF VEHICLE
12. STATE OF ISSUE
17. COMMANDING OFFICER'S SIGNATURE
I RECOMMEND THAT THIS INDIVIDUAL BE EXAMINED FOR
QUALIFICATION TO HOLD THE OF 346
(Date)
(Signature)
PART II EXAMINATION
18. QUALIFICATION TESTS (CHECK)
TEST
SAT
UNSAT
TEST
SAT
UNSAT
TEST
SAT
UNSAT
PHYSICAL
HEARING
VISION
WRITTEN
REACTION TIME
SKILL
ROAD
DIRT/CROSS COUNTRY
SPECIAL QUALIFICATION
19. RESTRICTIONS
CHECK HERE IF NONE
: (List)
PART III LICENSE ACTION
20. CATEGORY (Check One)
21. CLASS OF LICENSE (Check all that apply)
NEW
RENEW
UPGRADE
DUPLICATE
COMMERCIAL
TACTICAL
BUS
TRACTOR
22. CLASSES OF VEHICLES (Check all that apply)
SEDANS/STATION WAGONS
TRUCKS TO
TON
TRUCK-TRACTOR TO
TON
BUSSES TO
PASS
23. SPECIAL QUALIFICATIONS:
EMERGENCY VEHICLE
TRUCK WITH FULL TRAILER
SEMITRAILER REFUELER
RECOVERY VEHICLE
HAZARDOUS MATERIALS
OTHER (SPECIFY)
24. VEHICLE/EQUIPMENT CLASSES QUALIFIED TO OPERATE LIST:
25. SIGNATURE OF LICENSING EXAMINER
I CERTIFY THAT THIS INDIVIDUAL IS QUALIFIED TO OPERATE
THE ABOVE LISTED EQUIPMENT.
(Signature)
(Date)
26.
LICENSE
# ISSUED
27. DATE ISSUED
28. EXPIRATION DATE
29. SIGNATURE OF LICENSING OFFICER
DATE
PART IV RECORDING ACTION
30. RECORDING OFFICER'S SIGNATURE
SIGNATURE
DATE
I CERTIFY THAT ALL THE INFORMATION IN BLOCKS 19, 20, 23, 24, 26, 27,
AND 28 HAVE BEEN ENTERED ON PAGE 11 OF THE INDIVIDUAL'S SRB/OQR
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