Form Bmv 2380 - Application For Cdl/waiver For Farm Related Service Industries Page 2
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1
2SECTION 3: DRIVER LICENSE RECORDS
Answer all questions below by checking the appropriate box.
1. I hereby certify that my driving privileges are currently valid and not suspended,
revoked, cancelled, or disqualified in this or any other state.
Yes
No
2. I have operated a motor vehicle in the one year period immediately preceding today’s
date.
Yes
No
SECTION 4: CHECK THE APPROPRIATE BOX FOR EACH STATEMENT
ALL QUESTIONS MUST BE ANSWERED - NO EXCEPTIONS:
I certify that the answers to the following questions are correct and apply to my driving history for the two (2)
year period immediately preceding this application for a CDL Farm Waiver.
1. Have you had a driver license in more than one state at the same time?
Yes
No
2. Has your driver license been suspended, revoked, cancelled, or disqualified in this or
any other state?
Yes
No
3. Have you been convicted in any type of motor vehicle for:
A.
Driving while intoxicated, driving while under the influence of alcohol
(includes BAC) or driving while under a controlled substance.
Yes
No
B.
Leaving the scene of an accident.
Yes
No
C. A felony involving the use of a commercial motor vehicle.
Yes
No
D. Speeding 15 or more MPH over the posted speed limit.
Yes
No
E.
Reckless operation.
Yes
No
F.
Following too closely.
Yes
No
G. Improper lane change/lane violation.
Yes
No
H. A violation of vehicular homicide.
Yes
No
4. Have you been convicted of any county or municipal ordinance, or any state law relating
to the operation of any type of motor vehicle in connection with an at-fault crash?
Yes
No
5. Have you refused to submit to any test of your blood, breath, or urine for the purpose of
determining alcohol concentration or the presence of a controlled substance?
Yes
No
6. Have you violated an out of service order?
Yes
No
7. Have you violated any of the prohibitions described above while transporting hazardous
materials?
Yes
No
SECTION 5: ANSWER THE FOLLOWING DRIVER INFORMATION:
MARK THE TYPE OF VEHICLE YOU WILL BE DRIVING:
Straight Truck
Gross Vehicle Weight Rating (GVWR) Power Unit
GVWR Trailer
Air Brake Equipped?
Yes
No
Vehicle designed to carry 16 persons or more, including the driver.
Ibs. GVWR
Air Brake Equipped?
Yes
No
SECTION 6:
Each application for a CDL Farm Waiver requires a fee of $25.00.
APPLICANT’S SIGNATURE
If I make a false statement on this application and am issued a Restricted Commercial Driver License, I understand
that my license will be cancelled upon discovery and that I will not be permitted to make APPLICATION FOR ANY
TYPE OF LICENSE FOR A PERIOD OF ONE YEAR.
ANY PERSON GIVING FALSE INFORMATION IS SUBJECT TO PROSECUTION UNDER SECTIONS 4506.10
AND 4507.36 OF THE OHIO REVISED CODE.
APPLICANT’S SIGNATURE
TODAY’S DATE
X
BMV 2380 1/09 Page 2 of 2
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