Certification of Violations

Please check box:

I certify that I have not been convicted or forfeited bond or collateral on account of any violations (other than than those I have provided) required to be listed during the past 12 months.

Date: *

State: *

I certify these entries to be true and correct. *

Motor Vehicle Driver’s

CERTIFICATION OF VIOLATIONS

I certify that the following is a true and complete list of traffic violations that are required to be listed (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months.

Expiration Date: *

Driver's License # *

Violations (if applicable). Please enter: DATE, OFFENSE, LOCATION AND TYPE OF VEHICLE OPERATED.

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