353R08-RFQ - Attachment B - DL-408CD_2-15.pdf

APPENDIX B

COMMERCIAL DRIVER’S LICENSE THIRD

PARTY TRAINER APPLICATION (DL-408CD)

Name: ___________________________________________________ Phone No. ( ________________________

E-Mail Address: ____________________________________________ Fax No. ( ) ________________________

Address: P.O. Box number may be used in addition to the actual address, but cannot be used as the only address.

Description of Business _________________________________________________________________________________

STREET CITY STATE ZIP CODE

DL-408CD (2-15)

commercial driver’s license third party trainer application

(Complete Section A thru F)

❑ Initial

❑ Renewal

❑ Replacement

(Complete Section A and D and any other applicable Section)

❑ Change

❑ Correction section a company inFormation

Number of Years as a CDL 3rd Party Tester in PA: ___________________________________________________________

Number of PA CDL 3rd Party Examiners Employed (Include Full-Time, Part-Time examiners): _________________________

Has There Been Any Negative Audit Findings or Other Corrective Action Taken by the Department in the Past Five years: ............................................................................................................................................................❑ Yes ❑ No section B traininG inFormation

STREET CITY STATE ZIP CODE

Actual Training Site Address: _______________________________________________________________________________________

Training Site What Class of Vehicles will be Accommodated and will Phone Number: ( ) ___________________________ be Used for Training: ............................❑ A ❑ B ❑ C

Is This an Open Site Will You Have Access Traning Facility: ........................................❑ Yes ❑ No to a School Bus: ......................................❑ Yes ❑ No

Number of Refresher Training Candidates That Can be Cost Per Examiner for Refresher Training Trained Per Month (3 Day Course): __________________ (3 Day Course): ________________________________

Cost Per Examiner for Initial Training (5 Day Course): _________________________________

1. For initial, renewal or replacement. ENTIRE APPLICATION MUST BE COMPLETED.

2. For change or correction, Sections A and D must be completed, along with any applicable remaining Sections.

3. Attach a resume for each trainer.

4. Attach photographs of training facilites.

5. An official of the company must sign this application.

6. Attach a copy of the Third Party Examiner Certificate for each trainer listed in Section C.

7. If you need additional room to complete information, attach a separate sheet, listing your company name and the section you are continuing.

8. You will be notified by mail within 30 days regarding this application.

SIGNATURE OF COMPANY OFFICIAL TITLE DATE

DL-408CD (2-15)

section c employed trainer inFormation

Trainer’s Name: ________________________________________________________________ Resume Attached: ….…❑

Driver License Number: _____________________ Class: __________ Endorsements: __________ Restrictions: __________

Examiner Number: _______________________ Number of Years as a CDL 3rd Party Examiner: _______________________

Trainer’s Name: ________________________________________________________________ Resume Attached: ….…❑

Driver License Number: _____________________ Class: __________ Endorsements: __________ Restrictions: __________

Examiner Number: _______________________ Number of Years as a CDL 3rd Party Examiner: _______________________

Trainer’s Name: ________________________________________________________________ Resume Attached: ….…❑

Driver License Number: _____________________ Class: __________ Endorsements: __________ Restrictions: __________

Examiner Number: _______________________ Number of Years as a CDL 3rd Party Examiner: _______________________ section d contact person and siGnatUre BlocK

Contact Person: ______________________________________________________________________________________

Phone No.: ( ) _________________________ Email Address: ____________________________________________ application instrUctions