| Operator/Driver Full Name (First, Middle, Last): |
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| Social Security Number: |
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| Date Of Birth: |
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| Current Home Address: |
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| Current Home Phone: |
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| List All Aliases: |
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| State Lived In, Excluding California, During Last (7) Years: |
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| Company Name: |
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| Job Title/Classification: |
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| Drivers License Number: |
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| State: |
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| Expiration Date: |
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| License Class: |
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| Endorsements: |
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Medical Certificate |
| Medical Certificate Expiration Date: |
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NUMBER OF YEARS EXPERIENCE AS A TOW TRUCK OPERATOR/DRIVER IN THE FOLLOWING CLASSES:
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| Class A: |
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| Class B: |
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| Class C: |
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| Class D: |
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Operator/Driver Presently Enrolled In DMV Pull Notice Program |
| Operator/Driver Ever Been Convicted Of A Misdemaner Or Felony: |
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YES |
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NO |
| If Yes Explain Circumstances. Include crimes committed, Sections Violated, Date Of Convictions, Country, State, And County Where Crimes Were Committed: |
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| I certify the above information is true and correct, and no omissions have been made. |
THE OPERATOR AND DRIVER ARE ADVISED THAT GIVING FALSE INFORMATION TO PEACE OFFCER, ETHER ORALLY OR IN WRITING,IS A MISDEMENORPURSUANT TO VEICLE CODE SECTIONS 20 AND 31 |
| Name |
Operator/Owner Certification |
| Date: |
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| Name |
Tow Drivers Certification |
| Date: |
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| PRIVACY NOTICE: |
The Information Practices Act of 1977 (CC 1798.17) and the Federal Privacy Act of 1974 (PL 93-579) require that this notice be provided when collecting personal information from individuals. Providing the social security number is voluntary and is being requested for identification purposes only, however, the processing of this document may be hampered if you do not supply your social security number. |
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