Continuation page for:
Applicants
for positions involving the operation of a motor vehicle to transport youth
must answer the following questions:
A. Have you ever
been charged with driving while under the influence of alcohol or a controlled
substance?
YES
NO (go to C)
B. If your answer to
the preceding question is "YES", please explain.
(At a minimum, state the
date and location of the incident giving rise to the charge, the name of the
law enforcement agency which investigated the incident [e.g., XYZ Police
Department, XYZ County Sheriff's Office, etc.], the name and address of the
court which adjudicated the charge, and the disposition of the charge.)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
C. Have you ever
refused a law enforcement official's request to submit to a test (e.g., blood
alcohol test, breath analysis, or urinalysis) related to the official's
suspicion that you were driving while under the influence of alcohol or a
controlled substance?
YES NO (go to
E)
D. If your answer to
the preceding question is "YES", please explain.
(At a minimum, state the
date and location of the incident, the name of the law enforcement agency which
made the request, the name and address of the court which adjudicated any
charge which resulted from the refusal, and the disposition of any charge which
resulted from the refusal.)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
E. During the past 10 years, have you been involved in a traffic accident for which you were found to be at fault?
YES NO (go to
G)
F. If you answer to
the previous question is “YES”, please explain.
(At a minimum, state the
date and location of the accident, the name of the law enforcement agency that
investigated the accident, the name and address of the court which adjudicated
any charge which resulted from the accident, and the disposition of any charge
which resulted from the accident.)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
G. During the past 5
years, have you been cited for any moving traffic violations?
YES
NO (go to I)
H. If your answer to
the preceding question is "YES", please explain.
(At a minimum, state the
date and location of the violation, the name of the law enforcement agency that
issued the citation, the name and address of the court which adjudicated the
citation, and the disposition of the citation.)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I. According to AFI 34-801, para 5.9.1, a check
of your driving record is required as a condition of employment. You are responsible for obtaining a copy of
your driving record at your own expense.
This guidance applies to all positions that involve responsibility for
transporting youth regardless of whether this is a primary or incidental duty.
LICENSE
INFORMATION:
Driver's
License Issuing State and Number:
Driver's
License Expiration Date:
J. I declare under
penalty of perjury that the foregoing is true and correct. I understand the penalty for perjury is a
fine of up to $250,000 or imprisonment for up to 5 years, or both.
Name (Print)
Signature Date