EMPLOYER NOTIFICATION OF TRAFFIC VIOLATION
FOR COMMERCIAL DRIVER’S LICENSE (CDL)
(Not necessary for parking violations)
DATE:
TITLE:
STATE:
CITATION NO:
__City __Other
__Yes __No
STATE:
__Yes __No
NAME:
DEPARTMENT:
DRIVER’S LICENSE #:
DATE TICKETED:
TYPE OF TRAFFIC VIOLATION:
RESOLUTION OF CITATION:
VEHICLE OPERATED (check one): __Personal
WAS VEHICLE A COMMERCIAL MOTOR VEHICLE?
LOCATION OF OFFENSE (CITY/COUNTY):
ISSUING AGENCY:
DID VIOLATION RESULT IN LOSS OF DRIVING
PRIVILEGES? IF YES, PLEASE EXPLAIN:
Employee Signature Date
Supervisor: Send to the Human Resources Department within 24 hours of receipt.
APPENDIX E
FORM 21
Page 228 of 254
click to sign
signature
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