Department of Highway Safety & Motor Vehicles

Hazardous Materials Application Form

HazMat/Tanker Combined
Male Female
Black Blue Brown Dichromatic Gray Green Hazel Maroon Pink
Bald Black Blond Brown Gray Red-Auburn Sandy White
ft in


Mailing (If Different)

Yes No
Yes No
Air Force Army Navy Marines Coast Guard
Merchant Marines National Guard
Yes No

Previous Residential Address

Current Employer Information

Employer Information (If more than one)

Answer the following Questions by selecting Yes or No.

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No


I, the undersigned, have been informed that Federal regulations under 49 CFR 1572.11(c) impose a continuing obligation to disclose to the Transportation Security Administration (TSA) within 24 hours if I am convicted of, wanted, under indictment, or found not guilty by reason of insanity of any disqualifying crime, or adjudicated as lacking mental capacity or committed to a mental institution, renounce or lose my U.S. citizenship, or violate my immigration status and/or am ordered removed from the U.S. while I have a hazardous materials endorsement for a CDL.

The information I provided on this application is true, complete, and correct to the best of my knowledge and belief and is provided in good faith. I understand that a knowing and willful false statement or an omission of a material fact on this application can be punished by fine or imprisonment or both (see section 1001 of Title 18 Unites State Code) and may be grounds for denial of a hazardous materials endorsement.

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