Form 735-6766 - Application For Third-Party Tester Certificate Page 2
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2SECTION B (continued)
Has any partner in or owner, agent, officer, director or manager of the business, or shareholder who owns more than 20%
of the business been convicted of a crime involving moral turpitude, including but not limited to, homicide, assault,
kidnapping, a sexual offense, robbery, child pornography, fraud, forgery, perjury and theft or of a crime punishable as a
felony involving the use of a motor vehicle, or a crime punishable as a felony involving possession, manufacture or
distribution of a controlled substance?
YES
NO
List the names, business addresses and phone numbers of all owners, officers, directors, managers or shareholders of
your company, business, corporation or association who, directly or indirectly, supervise the individual(s) you have
selected to conduct Third Party Examinations for your organization or represent your organization (Use a separate page, if
necessary):
NAME
BUSINESS ADDRESS
TELEPHONE NUMBER
Does the Tester own, lease or rent vehicles that will be used for Third Party drive tests?
YES
NO
Does your organization or any affiliate or employee of your organization receive compensation to provide commercial
motor vehicle operator training? (A Tester may not test anyone for whom it has received compensation to train.)
YES
NO
Will you charge a fee for administration of the test or vehicle use?
If “Yes,” you must attach a schedule that details the fees charged for each service offered by the
YES
NO
Tester and notify DMV of any subsequent changes.
If your organization will be testing the general public (non-employees), what phone number(s) and/or internet address will
you use to schedule tests? _______________________________________________________
SECTION C
Do you have a training campus located in Oregon?
YES
NO
Do you have a course of instruction designed to teach students to drive Class A, B, or C commercial motor vehicles?
YES
NO
SECTION D
Please list all cities where you will offer testing services (each drive test route must be approved by DMV before use):
________________________________________________________________________________________________
________________________________________________________________________________________________
Do you employ a person or persons, including yourself, who meet or will meet examiner eligibility requirements detailed in
OAR 735-060-090?
YES
NO
If “Yes,” please provide the name(s): ___________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
SECTION E
I certify that the information entered on this form is true and correct to the best of my knowledge. I understand that false
information may be grounds for rejection of my application and/or cancellation of my certification. I also understand that, if
I am convicted of making a false statement, I can be fined or sentenced to jail or both, according to Oregon law. In
addition, I certify that I have reviewed, and will comply with the provisions of Oregon Administrative Rules, Chapter 735,
Division 60, and the signed Third Party Agreement.
NAME OF PERSON COMPETING THIS FORM (PLEASE PRINT)
TITLE
SIGNATURE
DATE
X
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