Code No. 4O3.10E5
CERTIFICATION OF PREVIOUS EMPLOYERS REQUIRING A COMMERCIAL DRIVER’S LICENSE
Name: _______________________________________________________________________
Social Security Number: _____________________________________________________
I certify that I have been employed by the following employers during the two years prior to the date stated below and that I was required to possess a commercial driver's license (CDL) during the term of my employment.
Company ____________________________________________________________________
Address ____________________________________________________________________
City/State/Zip ______________________________________________________________
Company _____________________________________________________________________
Address _____________________________________________________________________
City/State/Zip ______________________________________________________________
Company ____________________________________________________________________
Address _____________________________________________________________________
City/State/Zip _____________________________________________________________
Company _____________________________________________________________________
Address _____________________________________________________________________
City/State/Zip ______________________________________________________________
Company ____________________________________________________________________
Address ____________________________________________________________________
City/State/Zip _____________________________________________________________
Signature: __________________________________________________________________
Date: _______________________________________________________________________
Revised: 7-17-23