Your Name (required) [text* your-name] Your Email (required) [email* your-email] Address: [text address]

In what states have you held a valid driver’s license?[text state]

In what states have you held a valid driver’s license?[text statehaslicense]

1. Do you possess a current vehicle operator’s license?[select havelicense “Select” “Yes” “No”]

  Vehicle Operators License Other License (CDL, Chauffeur, etc.
State [text license1] [text license2]
Expiration [text expire1] [text expire2]
License # [text lnum1] [text lnum2]
  (As it appears on license)  

2. Have you ever had an operator’s license revoked or suspended?[select revoked “Select” “Yes” “No”]
If yes, please explain:
[textarea whyrevoked] 

3. List all moving violations and crashes you have had within the last 3 years. (If none, write “NONE” one per line)

1.[text violatonandcrashes1]
2.[text violatonandcrashes2]
3.[text violatonandcrashes3]
4.[text violatonandcrashes4]


 4. Have you ever received a citation for driving while under the influence of alcohol, drugs or other controlled substances?[select drugs “Select” “Yes” “No”] If yes, explain: textarea explaindrugs]

5. Have you ever been required to attend an alcohol offender’s school, traffic offender’s school or other remedial traffic school required by the courts?[select alcoholschool “Select” “Yes” “No”] If yes, explain:
[textarea yesalcoholschool]
6. Have you ever completed a driver’s education course?[select driversed “Select” “Yes” “No”] If yes, when? (Date):
[text drivereddate]

Browe Construction Company, Inc. will require all potential drivers to provide a copy of their Motor Vehicle Driving Record (MVR) prior to hiring. You can obtain a copy from your local Division of Motor Vehicles office or online at under the Online Services tab, under the Drivers tab, under Driving Record Request, “Order Record”. You may order a non-certified copy. Please fill in your information and pay the fee. Print out and bring a copy to this office for review.

I understand that all of the information provided on this form will be kept confidential, and certify that, to the best of my knowledge, the above information is correct. Any falsification may result in disciplinary action up to and including termination.

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