Form 665 - Experience Statement Sheet For Motor Vehicle And Mobil Equipment Operators
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1
2Form Approved
United States Civil Service Commission
Budget Bureau No. 50-R0279.
ABILITY TO DRIVE SAFELY
Experience Statement Sheet for Motor Vehicle and Mobil Equipment Operators
Please fill in both sides of this Form. You may have someone help you complete it if you wish.
A. General Information
1. Title of position applied for
2. Date
3. Name (First, middle, last)
4. Birth date (Month, day, year)
5. Address (Number and street, or RD number, city, state, and ZIP Code)
B. Traffic Violations. (Supply the information requested below for each time you were given a ticket or arrested for
breaking a driving law during the past 5 years. Do not include any record where you were found no guilty. Also do
not include parking tickets.)
Type of violation
Mo/Yr.
While
City County, State
License
Fined or
Sentenced?
on job?
revoked or
forfeited
1
suspended?
collateral?
Yes □
Yes □
Yes □
Yes □
No □
No □
No □
No □
Details of action taken (Length of suspension, amount of fine, etc.)
Type of violation
Mo/Yr.
While
City County, State
License
Fined or
Sentenced?
on job?
revoked or
forfeited
2
suspended?
collateral?
Yes □
Yes □
Yes □
Yes □
No □
No □
No □
No □
Details of action taken (Length of suspension, amount of fine, etc.)
Type of violation
Mo/Yr.
While
City County, State
License
Fined or
Sentenced?
on job?
revoked or
forfeited
3
suspended?
collateral?
Yes □
Yes □
Yes □
No □
No □
No □
Details of action taken (Length of suspension, amount of fine, etc.)
C. Driver’s License Information
Driver’s permit or license number
State in which it was issued
Date it expires
Restrictions listed in present license
Other States where you obtained license during the past 5 years
CSC Form 665
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