Annual certification of violations | MVR Review FORM Annual Certification Of Violations Annual Certification of Violations and Annual Review of Driving Record Annual Certification of ViolationsCompany Employed By* Rochester City Lines, 1825 N Broadway Ave, Rochester, MN 55906 | Tel. (507) 288-4353 | Fax. (507) 288-9318 Richfield Bus Company, 9237 Grand Ave S, Bloomington, MN 55420 | Tel. (952) 881-1111 | Fax. (952) 884-9190 Are you employed by any other employer at this time?* Yes No Name* First Last Email* Enter Email Confirm Email Driver's License Number* State of Issue* State / Province / Region Driver License Expiration Date* Month Day Year Please check this box to indicate whether you have had violations in the previous 12 Months* I have had no violations in the previous 12 months I have had violations in the previous 12 months Please enter all Violations of motor vehicle laws or ordinances (other than violations involving only parking) of which the commercial driver was convicted or forfeited bond or collateral during the last 12 months preceeding today's date. These will be verified with your Motor Vehicle Record.* None 1 2 3 4 Please enter all Violations of motor vehicle laws or ordinances (other than violations involving only parking) of which the commercial driver was convicted or forfeited bond or collateral during the last 12 months preceding today's date. These will be verified with your Motor Vehicle Record.1. Date of Occurence* Month Day Year 1. Nature of Violation* Speeding Lane Travel Equipment Collision 1. Location or Municipality* 1. Was this in a Commercial Motor Vehicle?* Yes No 1. Were Fatalities or Personal Injuries Sustained?* Yes No 2. Date of Occurence* Month Day Year 2. Nature of Violation* Speeding Lane Travel Equipment Collision 2 Location or Municipality* 2. Was this in a Commercial Motor Vehicle?* Yes No 2. Were Fatalities or Personal Injuries Sustained?* Yes No 3. Date of Occurence* Month Day Year 3. Nature of Violation* Speeding Lane Travel Equipment Collision 3. Location or Municipality* 3. Was this in a Commercial Motor Vehicle?* Yes No 3. Were Fatalities or Personal Injuries Sustained?* Yes No 4. Date of Occurence* Month Day Year 4. Nature of Violation* Speeding Lane Travel Equipment Collision 4. Location or Municipality* 4. Was this in a Commercial Motor Vehicle?* Yes No 4. Were Fatalities or Personal Injuries Sustained?* Yes No I CERTIFY THAT THE INFORMATION GIVEN ABOVE IS A TRUE AND ACCURATE STATEMENT OF MY RECORD OF MOTOR VEHICLE VIOLATIONS FOR THE PREVIOUS 12 MONTH PERIOD.* I CERTIFY THAT THE INFORMATION GIVEN ABOVE IS A TRUE AND ACCURATE STATEMENT OF MY RECORD OF MOTOR VEHICLE VIOLATIONS FOR THE PREVIOUS 12 MONTH PERIOD. READ THIS NOW. I understand that I will be Automatically Re-Directed to a digital Signature Page when I click the "SUBMIT" Button below. I also understand that I will need to digitally sign this document before it will be sent to the appropriate manager for review and verification.* I understand that I will be Automatically Re-Directed to a digital Signature Page when I click the "SUBMIT" Button below. I also understand that I will need to digitally sign this document before it will be sent to the appropriate manager for review and verification. Would you like to upload a copy of your MVR Now?Max. file size: 20 MB.SLOW DOWN!! When you click the SUBMIT button, you will be directed to a digital signature page. Please be patient while the tool loads after you click the SUBMIT button. After I click the SUBMIT button, I will wait for a few seconds while the electronic signature tool loads up.
