Form Haz-44 - Application For A Hazardous Materials Endorsement
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1
2APPLICATION FOR A HAZARDOUS MATERIALS ENDORSEMENT
PLEASE PRINT CLEARLY
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.
SECTION I - PERSONAL INFORMATION
I certify that I meet the federal medical requirements
NOTE: If you cannot answer YES or you do not have a valid
in 49CFR Part 391 and that I have a valid USDOT
Medical Examiner’s Certificate, do not complete this application
Medical Examiner’s Certificate.
because you are not eligible for a HazMat endorsement.
License ID No:
I am applying for a :
Combination HazMat & Tanker
HazMat
CDL Number (if available)
State
TYPE OF APPLICATION
If transferring, list prior CDL
New
Renewal
Transfer
number & state of issuance
LAST NAME
FIRST NAME
MIDDLE NAME
SUFFIX
DATE OF BIRTH
WEIGHT (LBS)
EYE COLOR
HAIR COLOR
HEIGHT
SEX
Month
Day
Year
Feet
Inches
Male
Female
PREVIOUS NAME USED (if any): LAST NAME
FIRST NAME
MIDDLE NAME
SUFFIX
Country of Birth (for example: USA, Canada, Mexico)
City of Birth
State of Birth (Not required if born outside the U.S.)
SECTION II - ADDRESSES
ADDRESS WHERE YOU GET YOUR MAIL - Include Street Number and Name, Rural Delivery and/or box number, or PO box number
Apt. No.
City or Town
State
Zip Code
Country
ADDRESS WHERE YOU LIVE
- IF DIFFERENT FROM MAILING ADDRESS (DO NOT GIVE P.O. BOX NUMBER)
Apt. No.
City or Town
State
Zip Code
Country
Work Phone (Include area code)
Cell Phone (Include area code)
E-Mail Address
Home Phone (Include area code)
(
)
(
)
(
)
PREVIOUS ADDRESS WHERE YOU LIVED (DO NOT GIVE P.O. BOX NUMBER)
Apt. No.
City or Town
State
Zip Code
Country
SECTION III - CITIZENSHIP
COUNTRY OF CITIZENSHIP
NATURALIZATION DATE (if applicable)
ALIEN REGISTRATION NO. (if you are a legal alien or a naturalized citizen)
Month
Day
Year
Are you a U.S. Citizen?
Yes
No
If born abroad to U.S. citizens, check the State Department Form Number
Legal Status Document Type
Assigned Number
Expiration Date (if applicable)
(see list below)
FS-240
FS-545
DS-1350
and provide number assigned: __________________________________
ACCEPTABLE DOCUMENTS FOR PROOF OF LEGAL STATUS
+
Certificate of Naturalization issued by the U.S. Department of Homeland
+
U.S. Passport (not expired)
Security (Form N-550 or N-570)
+
Certified copy of a birth certificate filed with a State Office of Vital Statistics or
+
Certificate of Citizenship issued by the U.S. Department of Homeland
equivalent agency in the applicant’s state of birth, Puerto Rico, Virgin Islands, Guam,
Security (Form N-560 or N-561)
American Samoa, or the Commonwealth of the Northern Mariana Islands
+
Permanent Resident Card (not expired) issued by USCIS or INS (Form I-551)
+
Consular Report of Birth Abroad issued by the U.S. Department of State
(Form FS-545 or DS-1350)
SECTION IV - EMPLOYMENT HISTORY
1. Have you undergone or are you undergoing a DHS
If yes: Name of program (e.g., Aviation Worker, Certified Cargo Screening, Indirect Air
Yes
No
(including TSA) security threat assessment?
Carrier, TWIC, FAST, MMD, etc.):
2. Have you had or do you have a DHS/TSA credential (e.g.,
If yes: Type of credential:
Aviation Worker, Certified Cargo Screening, Indirect Air
Yes
No
Carrier, TWIC, FAST, MMD, etc.)?
Credential reference number:
NAME OF YOUR CURRENT EMPLOYER
EMPLOYER’S PHONE NO.
Area Code
(
)
ADDRESS OF YOUR CURRENT EMPLOYER
City or Town
State
Zip Code
Country
This form is also available on DMV’s web site at: dmv.ny.gov
HAZ-44 (7/17)
PAGE 1 OF 2
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