Form HAZ-44 - Application for a Hazardous Materials Endorsement - New York

I am applying for a :
Combination HazMat & Tanker
HazMat
New York State Department of Motor Vehicles
APPLICATION FOR A HAZARDOUS MATERIALS ENDORSEMENT
Male Female
oo
PLEASE PRINT CLEARLY
LAST NAME
FIRST NAME
MIDDLE NAME SUFFIX
PREVIOUS NAME USED (if any): LAST NAME FIRST NAME
MIDDLE NAME
COUNTRY OF CITIZENSHIP
ALIEN REGISTRATION NO. (if you are a legal alien or a naturalized citizen)
SUFFIX
WEIGHT (LBS) SEXHEIGHTEYE COLOR
HAIR COLOR
PAGE 1 OF 2
Month Day Year
DATE OF BIRTH
Month Day Year
NATURALIZATION DATE (if applicable)
TYPE OF APPLICATION
If transferring, list prior CDL
number & state of issuance
ADDRESS WHERE YOU GET YOUR MAIL
- Include Street Number and Name, Rural Delivery and/or box number, or PO box number
ADDRESS WHERE YOU LIVE
Apt. No. City or Town State Zip Code
CDL Number (if available)
- IF DIFFERENT FROM MAILING ADDRESS (DO NOT GIVE P.O. BOX NUMBER)
Feet Inches
License ID No:
Apt. No. City or Town State Zip Code
PREVIOUS ADDRESS WHERE YOU LIVED (DO NOT GIVE P.O. BOX NUMBER)
Home Phone (Include area code)
( )
Work Phone (Include area code)
( )
Cell Phone (Include area code)
( )
E-Mail Address
Country of Birth (for example: USA, Canada, Mexico)
City of Birth State of Birth (Not required if born outside the U.S.)
Apt. No. City or Town State Zip Code
Country
Country
Country
This form is also available on DMV’s web site at: www.dmv.ny.gov
The federal Transportation Security Administration requires all drivers who are applying for a hazardous materials endorsement to complete and sign
this form. Be sure to provide all information requested on
pages 1 and 2. Mail the completed application and a copy of your legal status
document(s) to HazMat Unit, NYS DMV, 6 Empire State Plaza, Albany, NY 12228.
o New o Renewal o Transfer
Are you a U.S. Citizen?
o Yes o No
If born abroad to U.S. citizens, check the State Department Form Number
and
provide number assigned: __________________________________
Legal Status Document Type
(see list below)
Assigned Number Expiration Date (if applicable)
ADDRESS OF YOUR CURRENT EMPLOYER
City or Town
1. Have you undergone or are you undergoing a DHS
(including TSA) security threat assessment?
2. Have you had or do you have a DHS/TSA credential (e.g.,
Aviation Worker, Certified Cargo Screening, Indirect Air
Carrier, TWIC, FAST, MMD, etc.)?
If yes: Name of program (e.g., Aviation Worker, Certified Cargo Screening, Indirect Air
Carrier, TWIC, FAST, MMD, etc.):____________________________________________
If yes: Type of credential: _________________________________________________
Credential reference number: ______________________________________________
EMPLOYER’S PHONE NO.
Area Code
( )
NAME OF YOUR CURRENT EMPLOYER
ACCEPTABLE DOCUMENTS FOR PROOF OF LEGAL STATUS
u U.S. Passport (not expired)
u Certified copy of a birth certificate filed with a State Office of Vital Statistics or
equivalent agency in the applicant’s state of birth, Puerto Rico, Virgin Islands, Guam,
American Samoa, or the Commonwealth of the Northern Mariana Islands
u Consular Report of Birth Abroad issued by the U.S. Department of State
(Form FS-545 or DS-1350)
u Certificate of Naturalization issued by the U.S. Department of Homeland
Security (Form N-550 or N-570)
u Certificate of Citizenship issued by the U.S. Department of Homeland
Security (Form N-560 or N-561)
w Permanent Resident Card (not expired) issued by USCIS or INS (Form I-551)
HAZ-44 (2/13)
State
SECTION I - PERSONAL INFORMATION
SECTION II - ADDRESSES
SECTION III - CITIZENSHIP
SECTION IV - EMPLOYMENT HISTORY
o Yes o No
o Yes o No
o FS-240 oFS-545 oDS-1350
State Zip Code Country
I certify that I meet the federal medical requirements
in 49CFR Part 391 and that I have a valid USDOT
Medical Examiners Certificate.
NOTE: If you cannot answer YES or you do not have a valid
Medical Examiner’s Certificate, do not complete this application
because you are not eligible for a HazMat endorsement.
o
Yes
Page 1/2
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Form HAZ-44 - Application for a Hazardous Materials Endorsement - New York PDF

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