ATTACHMENT 5 - CHP 234 rev3.12.pdf

STATE OF CALIFORNIA

DEPARTMENT OF CALIFORNIA HIGHWAY PATROL

TOW OPERATOR/DRIVER INFORMATION

CHP 234F (Rev. 2-13) OPI 061

Instructions: Please type or print clearly. Form must be filled out completely.

OPERATOR/DRIVER FULL NAME (FIRST, MIDDLE, LAST) DATE OF BIRTH

LIST ALL ALIASES (USE ADDITIONAL PAGES IF NECESSARY)

STATES LIVED IN, EXCLUDING CALIFORNIA, DURING LAST SEVEN (7) YEARS

COMPANY NAME JOB TITLE/CLASSIFICATION

DRIVER LICENSE NUMBER STATE EXPIRATION DATE LICENSE CLASS ENDORSEMENTS

MEDICAL CERTIFICATE

YES NO

MEDICAL CERTIFICATE EXPIRATION DATE OPERATOR/DRIVER ENROLLED IN CSAT (DRUG /ALCOHOL TESTING) PROGRAM?

YES NO

NUMBER OF YEARS EXPERIENCE AS A TOW TRUCK OPERATOR/DRIVER IN THE FOLLOWING CHP CLASSES:

Class A: Class B: Class C: Class D:

OPERATOR/DRIVER PRESENTLY ENROLLED IN DMV PULL NOTICE PROGRAM?

YES NO

OPERATOR/DRIVER EVER BEEN CONVICTED OF A MISDEMEANOR OR FELONY?

YES NO

IF YES, EXPLAIN CIRCUMSTANCES. INCLUDE MISDEMEANOR/FELONY CONVICTIONS, SECTIONS OF LAW VIOLATED, DATES OF ALL CONVICTIONS AND LOCATIONS WHERE THEY OCCURRED

(CITY, COUNTY, STATE, COUNTRY). USE ADDITIONAL PAGES IF NECESSARY.

I certify the above information is true and correct, and no omissions have been made.

The Operator and Driver are advised that giving false information to a peace officer, either orally or in writing, is a misdemeanor pursuant to Vehicle Code Sections 20 and 31. A failure to disclose any felony and/or misdemeanor convictions shall be cause for denial of the CHP 234F.

OPERATOR'S/OWNER'S SIGNATURE DATE

TOW DRIVER'S SIGNATURE DATE

RECEIVING OFFICER'S NAME ID NUMBER DATE

FOR CHP USE ONLY:

APPROVED DISAPPROVED

If an individual is not approved, provide tow operator with a written reason for the action and attach a copy of the reason to this form.

Destroy Previous Editions Chp234F_0419.pdf

STATE OF CALIFORNIA

DEPARTMENT OF CALIFORNIA HIGHWAY PATROL

TOW OPERATOR/DRIVER INFORMATION

CHP 234F (Rev. 2-13) OPI 061 Instructions: Please type or print clearly. Form must be filled out completely.

MEDICAL CERTIFICATE

OPERATOR/DRIVER ENROLLED IN CSAT (DRUG /ALCOHOL TESTING) PROGRAM?

NUMBER OF YEARS EXPERIENCE AS A TOW TRUCK OPERATOR/DRIVER IN THE FOLLOWING CHP CLASSES:

OPERATOR/DRIVER PRESENTLY ENROLLED IN DMV PULL NOTICE PROGRAM?

OPERATOR/DRIVER EVER BEEN CONVICTED OF A MISDEMEANOR OR FELONY?

I certify the above information is true and correct, and no omissions have been made.

The Operator and Driver are advised that giving false information to a peace officer, either orally or in writing, is a misdemeanor pursuant to Vehicle Code Sections 20 and 31. A failure to disclose any felony and/or misdemeanor convictions shall be cause for denial of the CHP 234F.

OPERATOR'S/OWNER'S SIGNATURE

TOW DRIVER'S SIGNATURE

FOR CHP USE ONLY:

If an individual is not approved, provide tow operator with a written reason for the action and attach a copy of the reason to this form.

Destroy Previous Editions Chp234F_0419.pdf P:\work\CHP\new batch Forms\Chp234F.xft April 3, 2003 Chp234F Spelling Checker;{224F7DEA-B7C1-11D3-AB40-00902712A5C9};PLSSpeller.cab

<<076/ABS>>

Documentation on the form's macros located in m:\MACROS folder.

Ariel DelMundo Tow Operator Driver Information, CHP 234F

CHP

Tow Operator Driver Information, CHP 234F 8-04

Rvsn: 03/12 - Deleted Privacy Notice and changed footer - jc

01/11 - Changed OPI to 061 and verbiage on convictions field. - jc

Rev. 2-13: Minor Edits and adding. - JN

<<076/ABS>>

Documentation on the form's macros located in m:\MACROS folder.

Form 0419: fixed accessibility warnings, as required by AB 434 -dg Ariel DelMundo