Form Dot 4-764 Mvs - Application For Commercial Driver'S License

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DOT 4-764 MVS (07/15)

STATE OF HAWAII

FOR OFFICE USE ONLY

Verified By: ______

___

APPLICATION FOR COMMERCIAL DRIVER’S LICENSE

Date: __ ______________

(Print carefully – use ink or ball point pen)

INSTRUCTION PERMIT

ENDORSEMENT

LICENSE RENEWAL

CHECK

DUPLICATE (Temporary, Lost, Name Change/Address)

UPGRADE

TRANSACTION

OUT OF STATE TRANSFER

REINSTATEMENT

REQUESTED

SOCIAL SECURITY NUMBER

DATE OF BIRTH:

PLACE OF BIRTH

DAYTIME TELEPHONE

MO. | DAY | YEAR

NUMBER

NAME (Last, First, Middle)

Address to be printed on license

Mailing Address:

Principle Residence Address:

MAILING ADDRESS (Street and Apt. or House No. or P.O. Box, City, State, Zip Code)

HAWAII PRINCIPAL RESIDENCE ADDRESS (Street and Apt. or House

No., City, State, Zip Code)

HEIGHT

FT.

IN.

WEIGHT

LBS.

HAIR COLOR

COLOR EYES

IS THIS YOUR STATE OF

SEX:

MALE

DOMICILE?

Yes

FEMALE

BUSINESS

CURRENT DRIVER’S LICENSE (Number, Issuing State)

OCCUPATION

ADDRESS

MARK THE BOXES FOR CLASS OF LICENSE AND ENDORSEMENTS YOU NEED:

Class:

Air Brakes:

Yes

Endorsements:

Combinations:

Yes

ANSWER THE FOLLOWING QUESTION BY CHECKING THE APPROPRIATE BOX:

YES

1. Do you wish to be an organ/tissue donor? If yes, initial here: ________

2. Do you have an advance health care directive?

3. Do you wish to have a Veteran designation?

4. Do you wear contact lenses?

5. Do you meet the requirements listed in 49 CFR Part 383?

Check the type of driving you expect to perform. For an explanation of each driving operation, see back of this form.

Non-excepted interstate

Non-excepted intrastate

Excepted interstate

Excepted intrastate

6. Do you meet the requirements listed in 49 CFR Part 391?

7. Is your testing vehicle representative of the vehicle you plan to operate?

8. Do you have a driver’s license from more than one state or licensing jurisdiction?

9. Has any part of your driving privileges been suspended, revoked, refused, or cancelled by any state, jurisdiction or the federal

government? If yes, give date and briefly explain: _______

_________

10. Are you disqualified from operating a commercial vehicle by any state, jurisdiction or the federal government?

If yes, give date and briefly explain: ___________________________________________________________________________

HRS 286-III, HAR 19-122-1, 19-122-3, 19-122-23 and 19-122-302 mandate disclosure of my social security number for the application of a driver’s license or instruction

permit. My social security number is used to confirm my identity and maintain my license and driving records.

I agree to submit to a chemical test or tests of my blood, breath or urine for the purpose of determining the alcohol or drug content of my blood when testing is requested

by a police officer acting in accordance with Section 286-243, Hawaii Revised Statutes.

I, the undersigned, do hereby certify, under the penalty of perjury (HRS 286-111), that the above statements are to the best of my knowledge true and correct. I, the

undersigned, also certify that the vehicles I drive or plan to drive are representative of the class marked above (49 CFR 383.73(b)(2)).

APPLICANT’S SIGNATURE: ___________________________________________________________

DATE: _______________________

____________________________________ _________

_____________________________

____________________________

EXAMINER’S SIGNATURE

STATION #

DATE

FOR OFFICE USE ONLY

Restrictions:

Explanation