Motor Vehicle Driver’s Certification of Violations

Driver's Details

Driver's Name*

First Last

Today's Date*

Email*

Phone*

Social Security Number

Driving History

This is only in regards to the last 12 months or since the last time Pyro Shows ran a Motor Vehicle Report on your driver's license number.

Have you had any motor vehicle violations in the last 12 months (other than parking violations)?*

No, I have not had any violations.
Yes, you can find the details below...

Motor Vehicle Violations

Date of Conviction	Offense	Location	Type of Vehicle Operated

Use the + button to add another row if you need to report additional violations.

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months.

Certification

Motor Carrier's Name*

Pyro Shows, Inc.

Motor Carrier's Address*

PO Box 1776, La Follette, TN 37766

Statement of Certification*

I agree to the below statement

I certify that the above information is true. This is a complete list of traffic violations (other than parking tickets) for which I have been convicted or forfeited bond/collateral during the past 12 months.
I also provide consent to Pyro Shows to conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I understand that if the limited query conducted by Pyro Shows indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Pyro Shows without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent, Pyro Shows must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations.

Driver's Signature*

Pyro Shows