• This is to certify that I have not been convicted of, or forfeited bond for, a violation of a motor vehicle traffic law during the 1-year period stated below.
  • Period Covered

    From 1/01/2019

    To 1/01/2020

  • Please register and authorize the company in the D&A Clearinghouse before you return this form.

  • Date Format: MM slash DD slash YYYY


  • Date Format: MM slash DD slash YYYY

  • Violations

    Driver complete this section ONLY if you have been convicted of, or forfeited bond for, a violation of a motor vehicle traffic law during the 1-year period stated above.






  • I certify that this is an accurate and true record of any violations during the period from 1/1/19 through 1/1/20.