MOTOR VEHICLE DRIVER’S CERTIFICATION OF VIOLATIONS

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

Date

Offense

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 12 months.

Driver's Name:   

____11/20/2008      ___                                            I acknowledge online submission  
(Date of Certification)                                                 of this form is my authorized signature.
                                                                                   (Driver’s Signature)

_Dedicated Logistics, Inc._________________       _2896 Centre Pointe dr, St. Paul, MN 55113 __    
(Motor Carrier’s Name)                                             (Motor Carrier’s Address)

_____________________________________       _____________________________________    
(Reviewed By: Signature)                                           (Title)

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