Form 735-6767 - Application For Cdl Third-Party Examiner Certificate Page 2

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SECTION A (continued)
Please list all cities where you will conduct tests (each drive test route must be approved by DMV before use):
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Do you have a valid CDL Medical Certificate (and waiver, if applicable)?
YES
NO
What is the expiration date of your CDL Medical Certificate? ________________ Waiver expiration? ________________
Do you have:
At least three years commercial motor vehicle (CMV) driving experience?
YES
NO
At least two years experience as an instructor with a licensed commercial truck driving school?
YES
NO
At least two years experience training CMV drivers for private business or government agency?
YES
NO
At least two years of experience testing CDL drivers for a governmental licensing agency?
YES
NO
You must include, with this application, employer certification or other evidence that you meet at least one of
the above qualifications.
If you do not possess an Oregon CDL you must also include a copy of your state driving record, no more than
30 days old.
How long have you held a CDL? ________________
DL#: ________________
SECTION B (Completed by ODE applicants ONLY)
Have you been trained by the Oregon Department of Education as a behind-the-wheel examiner?
YES
NO
Date of course completion? ________________
Have you satisfied the requirements for School Bus Driver Training and Certification detailed in OAR 581-053-0006?
YES
NO
SECTION C (Completed by all applicants)
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. I further
certify that I have reviewed and will comply with the provisions of Oregon Administrative Rules, Chapter 735, Division 60.
SIGNATURE
DATE
X
SECTION D (Completed by tester)
I certify that the Tester, identified in Section A above, employs, or otherwise exercises oversight of, this Examiner
applicant, and the Examiner applicant meets all required qualifications.
NAME (PLEASE PRINT)
TITLE
SIGNATURE
DATE
X

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