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					                                                                                             Policy 850-Attachment 2
                                                                                                    Revised 05/17/05


                    NOTIFICATION OF MOVING VIOLATION
                            CONVICTION FORM

The Commercial Motor Vehicle Safety Act of 1986 requires that commercial drivers notify their employer
and the state that issued their license of all traffic violations (other than parking violations), including those
committed in a personal vehicle, for which the driver forfeited collateral or was convicted, within 30 days
after conviction. See reverse for listing of state agency addresses.

The following information is being provided by the below named driver to comply with the traffic violation
notification requirements of the Act.



Driver’s Full Name:________________________________________________________________________

Driver’s Address:__________________________________________________________________________

City:_________________________________ State or Province:________________ Zip:______________

Phone Number: (             )

Driver’s License Number:___________________________________ State or Province:________________


Date of Violation:__________________________________ Citation Number:________________________

Vehicle Operated (Check One):       ______ Personal      ______ Commercial (GVWR/GCWR 26,001 or more)

______ Other (describe):____________________________________________________________________

Location of Offense: City/Town:__________________ County:____________ State or Province:________

Nature of Violation:________________________________________________________________________

Disposition of Case (bail forfeiture, conviction with fine and/or loss of license, unconditional discharge, etc.):

________________________________________________________________________________________


Date of Conviction:_______________________________________



Driver’s Signature:_______________________________________ Date:____________________________




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                                                                                 Policy 850-Attachment 2
                                                                                        Revised 05/17/05



  MAILING ADDRESSES OF STATE MOTOR VEHICLE AGENCIES FOR
                RETURNING EXTRA LICENSES


Alabama Dept. of Public Safety      Indiana Bureau of Motor Vehicles    Nevada Dept of Motor Vehicles
Montgomery, AL 36102                Indianapolis, IN 46204              and Public Safety
                                                                        Carson City, NV 89711
Alaska Div of Motor Vehicle         Iowa Dept of Vehicles
Juneau, AK 99507                    Des Moines, IA 50306-9204           New Hampshire Division of
                                                                        Vehicles and Public Safety
Arizona Motor Vehicle Division      Kansas Dept. of Vehicle             Concord, NH 03305
Phoenix, AZ 85001                   Topeka, KS 66605
                                                                        New Jersey Motor Vehicle
Arkansas Office of Driver           Kentucky Div. of Driver Licensing   Services
Services Little Rock, AR 72203      Frankfort, KY 40622                 Trenton, NJ 08666

California Dept of Motor Vehicles   Louisiana Office of Motor           New Mexico Motor Vehicle
Sacramento, CA 95818                Vehicles Baton Rouge, LA 70896      Division
                                                                        Santa, Fe. NM 87504-1028
Colorado Motor Vehicle Division     Main Motor Vehicle Division
Denver, CO 80204-5195               Augusta, ME 04333                   New York Dept of Motor
                                                                        Vehicles
Connecticut Dept of Motor           Maryland Motor Vehicle              Albany, NY 12228
Vehicles                            Administration
Wethersfield, CT 06109-1896         Glen Burnie, MD 21062               North Carolina Division of Motor
                                                                        Vehicles
Delaware Div of Motor Vehicles      Massachusetts Registry of Motor     Raleigh, NC 27697
Dover, DE 19903                     Vehicles
                                    Boston, MA 02114                    North Dakota Drivers License and
District of Columbia Bureau of                                          Traffic Safety Division
Motor Vehicle Services              Michigan Dept of State              Bismarck, ND 58505-0700
Washington, DC 2001                 Lansing, MI 48918
                                                                        Ohio Bureau of Motor Vehicles
Florida Div of Driver Licenses      Minnesota Driver & Vehicle          Columbus, OH 43232
Neil Kirkman Bldg.                  Services
Tallahassee, FL 32399               St. Paul, MN 55155                  Oklahoma Driver License
                                                                        Services
Georgia Dept. of Public Safety      Mississippi Driver Services         Oklahoma City, OK 73136
Atlanta, GA. 30371                  Bureau
                                    Jackson, MS 39205                   Oregon Motor Vehicle Division
Hawaii Motor Vehicle Safety                                             Salem, OR 97314
Office                              Missouri Transportation Systems
Honolulu, HI 96813                  Jefferson City, MO 65105            Pennsylvania Dept of
                                                                        Transportation
Idaho Motor Vehicle Bureau          Montana Motor Vehicle Division      Harrisburg, PA 17120
Boise, ID 83707-1129                Helena, MT 59620
                                                                        Rhode Island Division of Motor
Illinois Driver Services Dept       Nebraska Dept of Motor Vehicles     Vehicles
Springfield, IL 27623               Lincoln, NE 68509                   Providence, RI 02903




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                                                                             Policy 850-Attachment 2
                                                                                    Revised 05/17/05

South Carolina Dept of Highways   Utah Driver License Division      West Virginia Division of Motor
and Public Transportation         Salt Lake City, UT 84130          Vehicles
Columbia, SC 29216                                                  Charleston, WV 25317
                                  Vermont Dept of Motor Vehicles
South Dakota Dept of Commerce     Montpelier, VT 05603              Wisconsin Division of Motor
and Regulations                                                     Vehicles
Pierre, SD 57501                  Virginia Dept of Motor Vehicles   Madison, WI 53707-7918
                                  Richmond, VA 23269
Tennessee Dept of Safety                                            Wyoming Field Services Division
Nashville, TN 37210               Washington Dept of Motor          Cheyenne, WY 82002
                                  Vehicles
Texas Dept of Public Safety       Olympia, WA 98504
Austin, TX 78761-5999




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