HP 404 (07/01/2020)
TEST RESULTS
CSR STAMP
ACTION REQUEST FEECERTIFICATION REQUEST FEE
CSC NAME (print)
DMV USE ONLY
DRIVER'S LICENSE NUMBER
ISSUE STATE
CSC LOCATION CODE
CSR NAME (print)
CONTACT TELEPHONE NUMBER
CSC FAX NUMBER
TRAINING SITE CODE
APPLICANT SIGNATURE (sign full legal name)
DATE (mm/dd/yyyy)
APPLICANT CERTIFICATION
I certify that I currently hold a valid driver's license that is not expired, suspended, revoked or canceled in any state and hereby
authorize DMV to review my driving record.
I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV
are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and
affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a
criminal violation.
SEX
APPLICANT FULL LEGAL NAME (print) (last,first,mi)
BIRTH DATE (mm/dd/yyyy)
FEMALEMALE NON-BINARY
DRIVER LICENSE NUMBER (as it appears on your license)
STATE/PROVINCE (that issued your driver license)
PHYSICAL ADDRESS (include street name, number, apartment number, rural delivery)
CITY
ZIP CODE
JURISDICTION (CITY, COUNTY, TOWN)
MAILING ADDRESS OR P. O. BOX (where your mail is delivered)
CITY ZIP CODE JURISDICTION (CITY, COUNTY, TOWN)
CHECK IF PHYSICAL ADDRESS HAS CHANGED
CHECK IF MAILING ADDRESS HAS CHANGED
APPLICANT INFORMATION
EMAIL
STATE
STATE
ACTION REQUEST
ELIGIBILITY REQUIREMENTS
• be at least 18 years of age
• hold a valid driver's license
• satisfactory proof of successful completion of an 8-hour escort vehicle driver training course approved by Virginia DMV
ESCORT VEHICLE DRIVER
CERTIFICATION APPLICATION
Applicant for a duplicate, reissue or update may submit the completed application to any Virginia DMV Customer Service Center or mail
the completed application and fee to the attention of the Hauling Permit Office at the address above for processing.
Duplicate Certificate - lost, mutilated,
damaged, stolen ($15 fee)
Reissue Certificate - change of name,
driver's license number and/or driver's
license issue state ($15 fee)
Change of address or contact
information (No fee)
Renewal Certification ($25 fee)Original Certification ($25 fee)
Applicant for an original or renewal certification must submit the completed application to any Virginia DMV Customer Service Center,
pass the escort vehicle driver certification knowledge test, and pay the fee for certificate issuance.
CERTIFICATION REQUEST
TELEPHONE NUMBER
SOCIAL SECURITY NUMBER
REEXAM
PASS
FAIL
TEST DATE(mm/dd/yyyy)
ORIGINAL $25 RENEWAL $25 REEXAM $2
DUPLICATE $15
UPDATE (no fee)REISSUE $15
Note: Va. Code §46.2-2906 (B) requires that you provide DMV with the information on this form (including your social security number). This social security
number is for record keeping purposes and may be disseminated only in accordance with Va. Code §§46.2-208 and 46.2-209.
Purpose: Use this form to apply for certification to escort vehicles of excessive size or weight.
Instructions: Print legibly in black or blue ink.
Original or Renewal Certification Requests/fees must be submitted to any Virginia DMV Customer Service Center.
Action Requests/fees may be submitted to any Virginia DMV Customer Service Center or to the Hauling Permit Office at the
address above.
EXPIRATION DATE (mm/dd/yyyy)
