Form 735-6767 - Application For Cdl Third-Party Examiner Certificate

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FOR OFFICE USE ONLY
APPLICATION FOR CDL THIRD-PARTY
DENIED__________________
EXAMINER CERTIFICATE
APPROVED_______________
AN EXAMINER CONDUCTS TESTS AS AN EMPLOYEE,
CLASS___________________
OR UNDER THE OVERSIGHT, OF A TESTER
ENDORSEMENTS__________
INSTRUCTIONS:
RESTRICTIONS____________
COMPLETE BOTH SIDES OF THIS APPLICATION, SIGN IT AND RETURN IT TO:
ATTN: CDL POLICY UNIT
CERT. NO.________________
DRIVER AND MOTOR VEHICLE SERVICES
ISSUE DATE_______________
1905 LANA AVE NE
EXPIRATION DATE_________
SALEM OR 97314-4240
SECTION A (Completed by all applicants)
NAME (LAST, FIRST, MIDDLE)
HOME PHONE NUMBER
E-MAIL (WORK)
CELL PHONE NUMBER
(
)
(
)
STREET ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
MAILING ADDRESS (IF DIFFERENT)
CDL THIRD PARTY TESTER
SCHOOL DISTRICT (IF THE TESTER IS ODE)
PHONE NUMBER
(
)
STREET ADDRESS (PUPIL TRANSPORTATION SECTION IF TESTER IS ODE)
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
MAILING ADDRESS (IF DIFFERENT)
For what class of vehicles will you be testing (check all that apply)?
Class A
(Combination vehicles towing trailers with gross vehicle weight ratings (GVWR) of more than 10,000
pounds and a total GCWR of more than 26,000 pounds.)
Class B
(Single vehicles with GVWRs of more than 26,000 pounds.)
Class C
(Single vehicles with GVWRs of 26,000 pounds or less that carry 16 or more passengers, including the
driver, or hazardous materials.)
Passenger Vehicle (Vehicle designed to carry 16 or more passengers, including the driver.)
School Bus
(Oregon Department of Education ONLY)
Do you, your employer(s) or your Third Party Tester organization provide training for commercial motor vehicle operators?
(If you, your employer or your Third Party Tester have been compensated for training an individual, you may not test that
same individual.)
YES
NO
Have you 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?
YES
NO
If "Yes," where and when?______________________________________________________
Have you 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
Have you participated in a DUII diversion program within the last three years?
YES
NO
Have your driving privileges been restricted or suspended under a driver improvement program within the last three
years?
YES
NO
Have you been convicted of a major traffic crime within the last five years? (A major traffic crime is a traffic offense that is
punishable by a jail sentence.)
YES
NO
(CONTINUE ON REVERSE)
735-6767 (4-16)

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