DAVID | Driver and Vehicle Information Database

STATE OF FLORIDA

Department of Highway Safety & Motor Vehicles

Hazardous Materials Application Form

HazMat
HazMat/Tanker Combined

Bald Black Blond Brown Gray Red-Auburn Sandy White

ft in

Yes No

Answer the following Questions by selecting Yes or No.

1. Have you been convicted or found not guilty by reason of insanity of any disqualifying crime listed in Section 1, Part A, in any jurisdiction, civilian or military, during the seven years before the date of this application?:

Yes No

2. Have you been released from incarceration in any jurisdiction, civilian or military, for committing any disqualifying crime listed in Section 1, Part A during the five years before the date of this application?:

Yes No

3. Have you been convicted or found not guilty by reason of insanity of any disqualifying crime listed in Section 1, Part B, in any jurisdiction, civilian or military?:

Yes No

4. Are you wanted or under indictment in any jurisdiction, civilian or military, of any disqualifying crime listed in Section 1?:

Yes No

5. Have you been adjudicated as lacking mental capacity or committed to a mental institution involuntarily?:

Yes No

6. Do you meet the eligibility requirements for immigration status? (see Section 2):

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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STATE OF FLORIDA

Hazardous Materials Application Form

Residence

Mailing (If Different)

Previous Residential Address

Current Employer Information

Employer Information (If more than one)

Answer the following Questions by selecting Yes or No.

Agreement

STATE OF FLORIDA

Hazardous Materials Application Form

Residence

Mailing (If Different)

Previous Residential Address

Current Employer Information

Employer Information (If more than one)

Answer the following Questions by selecting Yes or No.

Agreement

Acknowledgment