MOTOR VEHICLE DRIVING RECORD FORM

Instructions to user:  Please print this form and submit a hardcopy to the Physical Plant.

Name in full:___________________________________________

License number and class: ________________________________

State: _______________________________

Birth date: ___________________________

Expiration date: _______________________

Have you had any moving violations in the past 12 months? Yes___ No___

If Yes, give Date, Place and Nature of the violation/s:___________________
______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

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Signature of License Holder