Due to the fact that you have an out-of-state/country driver's license we need you to complete this form.

NOTARIZED STATEMENT OF DRIVING RECORD

I have had a valid drivers license for two or more years? _______ yes _______no.

 I have been ticketed for the following moving violations (if none, please enter "None"):

____________________        _______________________________________ 

____________________        _______________________________________

____________________        _______________________________________ 

         Date /Offense                                                    Describe Offense

 

I have been involved in the following accidents (if none, please enter "None"); if you have been involved in any accidents within the past three years, please give a brief description of the accident(s) and  whether you received a citation for these:

____________________        ______________________________________ 

____________________        ______________________________________

____________________        _____________________________________

                 Date/Accident                                        Describe Accident

 

 

This is to certify that I  ___________________________________   presently hold a valid drivers license from the State/Country of ________________  and that violations/accidents listed above are accurate.

   ______________________           _________________________________

                    (Date)                                                                    (Signature of Driver)

 

Subscribed and sworn to before me this _______day

of ________________________, 20______________

My commission expires _______________________

____________________________________________

                 (Notary Signature) (SEAL)