Annual List of Violations Form

This form is an example only. Requirements for the annual driver’s certification of violations can be found in 49 CFR 391.27.

ANNUAL DRIVER’S CERTIFICATION OF VIOLATIONS

MOTOR CARRIER INSTRUCTIONS: Each motor carrier must at least once every 12 months, require each driver to prepare a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or of which he/she has forfeited bond or collateral during the preceding 12 months (49 CFR 391.27). Drivers who have provided information required by 49 CFR 383.31 need not repeat that information on this form.

DRIVER REQUIREMENTS: Each driver will provide the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of, any violation which must be listed, he/she shall so certify (49 CFR 391.27).

COMPLETED BY DRIVER – CERTIFICATION OF VIOLATIONS

Driver name: Last, First, Mi
Date of employment
Home terminal (city and state)
Driver's license number
State
Expiration date
I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under 49 CFR 383) for which I have been convicted orforfeited bond or collateral during the past 12 months.
- Check this box if you have had no violations in the past 12 months
Hidden
1 row
Date
Offence
Location
Type of vehicle operated
Hidden
2 row
Date
Offence
Location
Type of vehicle operated
Hidden
3 row
Date
Offence
Location
Type of vehicle operated
Hidden
4 row
Date
Offence
Location
Type of vehicle operated
Hidden
5 row
Date
Offence
Location
Type of vehicle operated
If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12months.
Motor carrier name
Motor carrier address
Reviewer printed name
Title
Date
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