Missouri 5140 Form

Applicant

Information

Name (Last, First, and Middle)

Driver License Number

Residence Address (Street)

City

State

ZIP Code

County

Mailing Address (If Different)

City

State

ZIP Code

County

During the two years before today’s date:

• Have you had more than one license (except for a military license)?

r Yes

r No

•

Has your license been suspended, revoked, cancelled, or disqualified in this or any other state?

r Yes

r No

• Have you been convicted of causing a fatality through the negligent operation of a commercial motor vehicle?

r Yes

r No

•

Have you been convicted of using any vehicle in the commission of a felony involving the manufacturing, distributing,

or dispensing of a controlled substance?

r Yes

r No

• Have you been convicted of driving a commercial motor vehicle without a commercial license?

r Yes

r No

• Have you been convicted of driving a commercial motor vehicle without a commercial license in your possession?

r Yes

r No

• Have you been convicted of driving a commercial motor vehicle without the proper class or endorsements for a specific CDL

group being operated or for the passengers or type of cargo being transported?

r Yes

r No

• Have you been convicted of driving a commercial motor vehicle while using a hand-held mobile phone?

r Yes

r No

• Have you been convicted of driving a commercial motor vehicle while texting?

r Yes

r No

•

Have you been convicted of driving while intoxicated or driving while under the influence of alcohol (includes BAC)?

r Yes

r No

•

Have you been convicted of driving while under a controlled substance or refusal to submit to an alcohol test?

r Yes

r No

• Have you been convicted of leaving the scene of an accident?

r Yes

r No

• Have you been convicted of a felony involving a motor vehicle?

r Yes

r No

• Have you been convicted of speeding 15 or more MPH over the posted speed limit?

r Yes

r No

• Have you been convicted of careless and imprudent driving?

r Yes

r No

• Have you been convicted of following too closely?

r Yes

r No

• Have you been convicted of improper lane change?

r Yes

r No

•

Have you been convicted of a violation in connection with a fatal accident?

r Yes

r No

•

Have you been convicted of any military, state law or county or municipal ordinance relating to the operation of any type

of motor vehicle in connection with an accident?

r Yes

r No

•

Have you had more than one conviction for any type of motor vehicle for serious traffic violations?

r Yes

r No

Have you been regularly employed in the last year in a military position requiring operation of a commercial motor vehicle,

were you exempted from the CDL requirements in 383 .3(c) and have you operated the representative vehicle which you

operate or expect to operate for at least the two years immediately preceding separation from the military?

r Yes

r No

Is the military vehicle you have operated representative of the commercial motor vehicle you currently operate or expect to

operate?

r Yes

r No

Applicant’s Signature

Title

Printed Name

Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Commanding Officer’s Name (Last, First, and Middle)

Telephone Number

(___ ___ ___)___ ___ ___-___ ___ ___ ___

Residence Address (Street)

City

State

Zip Code

County

Class

Vehicle Description

Example Of Vehicles In Group

* 5th Wheel - Truck Tractor or Semitrailer

Any combination of vehicles with a GCWR of 26,001 or

r A

more pounds provided the GVWR of the vehicle(s) being

towed is in excess of 10,000 pounds .

* Pintle Hook - Truck Trailer Combination

r A

Any combination of vehicles with a GCWR of 26,001 or

more pounds provided the GVWR of the vehicle(s) being

towed is in excess of 10,000 pounds .

r B

Any single vehicle with a GVWR of 26,001 or more pounds

or any such vehicle towing a vehicle not in excess of 10,000

pounds GVWR .

The service member is qualified to operate:

Vehicles equipped with a full air brake system;

r Yes

r No

Vehicles equipped with air-over-hydraulic braking system;

r Yes

r No

Vehicles with an automatic transmission;

r Yes

r No

A Passenger Vehicle designed to transport 16 or more people;

r Yes

r No

A Tank Vehicle

r Yes

r No

Commanding Officer’s Signature

Title

Printed Name

Date (MM/DD/YYYY)