Form 735-6766 - Application For Third-Party Tester Certificate
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1
2APPLICATION FOR CDL THIRD-PARTY
FOR OFFICE USE ONLY
DENIED__________________
TESTER CERTIFICATE
APPROVED_______________
A TESTER EMPLOYS OR EXERCISES OVERSIGHT OF THE
EXAMINER(S) WHO ACTUALLY CONDUCTS THE TESTS
CLASS___________________
ENDORSEMENTS__________
INSTRUCTIONS:
RESTRICTIONS____________
COMPLETE BOTH SIDES OF THIS APPLICATION, SIGN IT AND RETURN IT TO:
CERT. NO.________________
ATTN: CDL POLICY UNIT
DRIVER AND MOTOR VEHICLE SERVICES
ISSUE DATE_______________
1905 LANA AVE NE
SALEM OR 97314
EXPIRATION DATE_________
APPLICATION IS BEING SUBMITTED BY (Check One):
A COMPANY, BUSINESS, CORPORATION OR ASSOCIATION (Complete Sections A, B, D and E)
A FEDERAL, STATE, COUNTY OR MUNICIPAL AGENCY OTHER THAN OREGON DEPARTMENT OF EDUCATION
(Complete Sections A, D and E)
OREGON DEPARTMENT OF EDUCATION (Complete Sections A and E)
A PUBLICLY-OWNED EDUCATIONAL FACILITY (Complete Section A, C, D and E)
SECTION A
NAME OF CDL THIRD PARTY TESTER
BUSINESS TELEPHONE NUMBER
FAX NUMBER
E-MAIL (WORK)
(
)
(
)
STREET ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
MAILING ADDRESS (IF DIFFERENT)
Is your office or facility located in Oregon and is it staffed during normal business hours or is a business phone with answering
capability available that will permit you to return all business-related messages no later than the following business day?
YES
NO
What types of vehicles will your organization be testing (check all boxes that apply)?
Class A
Class B
Class C
Passenger Vehicles
School Bus
Hazmat
(Oregon Dept. of Education Only)
Will your organization not be testing certain vehicles due to restrictions that appear on your Examiner's CDLs (Check any
applicable restriction code boxes)?
(E) Auto Transmission CMV
(L) No Airbrake CMV
(M) No A Passenger CMV
(N) No A or B Passenger CMV
(O) No Tractor-Trailer
(Z) No Full Airbrake CMV
Do you have a commercial motor vehicle available that will accommodate a driver and two passengers?
YES
NO
Who will act as your “CDL Tester Representative” as required in OAR 735-060-0030?
Name: _____________________________________________
SECTION B
Is your business in compliance with all federal, state and local laws or regulations, including all business and zoning
requirements, that are related to Third Party Testing in Oregon?
YES
NO
Your business must have a business name that is registered and listed as active with the Corporation Division of the
What is your registry number? _________________________
Oregon Secretary of State.
If your company is a motor carrier subject to U.S. DOT regulations, please enter your U.S. DOT number: _____________
What is your most recent DOT safety rating?
Satisfactory
Unsatisfactory
None
Has your business, any partner in or owner, agent, officer, director or manager of the business, or shareholder who owns
more than 20% of the business, had Third Party Tester or Examiner certification or a driver training school or driver
training instruction certificate or equivalent involuntarily terminated, suspended or revoked in any state within the past five
years?
If “Yes,” where and when?___________________________________________________________
YES
NO
(CONTINUE ON REVERSE)
735-6766 (9-16)
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