Hazardous Materials Endorsement Application Form. This is a Maryland form and can be use in Motor Vehicle Administration Statewide.
Tags: Hazardous Materials Endorsement Application, DL-192, Maryland Statewide, Motor Vehicle Administration
Motor Vehicle Administration 6601 Ritchie Highway, N.E. Glen Burnie, Maryland 21062 DL-192 (1-05) Maryland Hazardous Materials Endorsement Application Shaded area for Department use only State CDL was issued (SOR): MARYLAND MD Driver’s License # Printed Last Name First Name Middle Name Suffix Printed Last Name (AKA or Alias) First Name (AKA or Alias) Middle Name (AKA or Alias) Suffix (AKA or Alias) Social Security Number Telephone No. (With Area Code) Endorsement Type ❑ Hazmat ❑ Hazmat/Tanker Combined Sex Eye ❑ Male ❑ Female Color: ❑ Black ❑ Blue ❑ Brown ❑ Dichromatic ❑ Grey ❑ Green ❑ Hazel ❑ Maroon ❑ Pink Height (ft. and in.) Weight (lbs.) Hair Color: ❑ Bald ❑ Black ❑ Blond ❑ Brown ❑ Gray ❑ Red/Auburn ❑ Sandy ❑ White Residence Street Address City Mailing Address (if Different) Date of Birth City State/Province ❑ Yes ❑ No Country of Birth Naturalization Date (if Naturalized US Citizen) If Yes, Which Branch?: Zip Code Zip/Postal Code State of Birth City of Birth Country of Citizenship U.S. Military Service? State Country Alien Registration No. (If Lawful Permanent US Resident) ❑ Air Force ❑ Army ❑ Navy ❑ Marine ❑ Coast Guard ❑ Merchant Marine ❑ National Guard Discharge Date Dishonorable Discharge ❑ Yes ❑ No Previous Residence Address Residence Street Address City State/Province Current Employer Name Current Employer Street Address Country Telephone No. (including Area Code) City or Municipality State/Province Current Employer Name (If More Than One) Current Employer Street Address (If More Than One) Zip/Postal Code Zip/Postal Code Country Telephone No. (Including Area Code) City or Municipality State/Province Zip/Postal Code Country Answer the following questions by checking the appropriate box 1. Have you been convicted or found not guilty by reason of insanity of any disqualifying crime listed in Section 1, Part A, in any jurisdiction, civilian or military, during the seven years before the date of this application? ............................. ❑ Yes ❑ No 2. Have you been released from incarceration in any jurisdiction, civilian or military, for committing any disqualifying crime listed in Section 1. Part A, during the five years before the date of this application? .................................................... ❑ Yes ❑ No 3. Have you been convicted or found not guilty by reason of insanity of any disqualifying crime listed in Section 1. Part B, in any jurisdiction, civilian or military? ........................................................................................................ ❑ Yes ❑ No 4. Are you wanted or under indictment in any jurisdiction, civilian or military, of any disqualifying crime listed in Section 1? .... ❑ Yes ❑ No 5. Have you been adjudicated as lacking mental capacity or committed to a mental institution involuntarily? ........................... ❑ Yes ❑ No 6. Do you meet the eligibility requirements for immigration status? (See Section 2) .................................................................. ❑ Yes ❑ No I, the undersigned, have been informed that Federal regulations under 49 CFR 1572.11(c) impose a continuing obligation to disclose to the Transportation Security Administration (TSA) within 24 hours if I am convicted of, wanted, under indictment, or found not guilty by reason of insanity of any disqualifying crime, or adjudicated as lacking mental capacity or committed to a mental institution, renounce or lose my U.S. citizenship, or violate my immigration status and/or am ordered removed from the U.S. while I have a hazardous materials endorsement for a CDL. The information I have provided on this application is true, complete, and correct to the best of my knowledge and belief and is provided in good faith. I understand that a knowing and willful false statement or an omission of a material fact on this application can be punished by fine or imprisonment or both (see Section 1001 of Title 18 United States Code) and may be grounds for denial of a hazardous materials endorsement. Applicant’s Signature Witnessed By (Licensing Representative) Date Signed Location Signed Date Signed For more information, please call: 1-800-638-8347 (touch tone calls only), 1-800-950-1MVA (1682) (to speak with a customer service representative), From Out-of-State: 1-301-729-4550, TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.marylandmva.com American LegalNet, Inc. www.FormsWorkFlow.com Section 1. List of Disqualifying Criminal Offenses for Hazardous Materials Endorsement Part A. Interim Disqualifying Offenses These crimes are only disqualifying if they are considered felonies in the appropriate jurisdiction, civilian or military. A driver will be disqualified from holding a hazmat endorsement if he or she was convicted* or found not guilty by reason of insanity within the last seven years or was release from prison within the last five years for any of the following crimes: • • • • • • • • • • • • • • Assault with intent to murder Kidnapping or hostage taking Rape or aggravated sexual abuse Unlawful possession, use, sale, manufacture, purchase, distribution, receipt, transfer, shipping, transporting, delivery, import, export, or dealing in a firearm or other weapon Extortion Dishonesty, fraud, or misrepresentation, including identity fraud Bribery Smuggling Immigration violations Violations of RICO (Racketeer influenced and Corrupt Organizations) Act or a comparable state law of an Interim Disqualifying crime Robbery Distributions of, possession with intent to distribute, or importation of a controlled substance (State laws vary on the quantity of marijuana required for the offense to be considered a felony. Typically, however, to be convicted to be convicted of felony marijuana possession, a person must possess a quantity of marijuana greater than an amount considered for “personal use”.) Arson Conspiracy or attempt to commit any of these crimes. Part B. Permanently Disqualifying Criminal Offenses A driver will be permanently disqualified from holding a hazmat endorsement on a CDL if he or she was ever convicted or found not guilty by reason of insanity of any of the following crimes: • • • • • • • • • • Espionage Sedition Treason Any crime listed in 18 U.S.C. Chapter 113B – Terrorism or a comparable state law A crime involving a severe transportation security incident (i.e., security incident involving a significant loss of life, environmental damage, transportation system disruption, or economic disruption in a particular area) Improper transportation of a hazardous material under 49 U.S.C. 5124 or a comparable state law (minor infractions involving transportation of hazardous materials will not disqualify a driver. For instance, no driver will be disqualified for minor roadside infractions or placarding violations.) Unlawful possession, use, sale, distribution, manufacture, purchase, receipt, transfer, shipping, transporting import, export, storage of, or dealing in an explosive or explosive device Murder as defined in 18 U.S.C. 1111 Conspiracy or attempt to commit any of these crimes Violations of RICO (Racketeer Influence and Corrupt Organization) Act or a comparable state law of one of these Permanently Disqualifying crimes Part C. Under Want or Warrant A driver will be disqualified from holding a hazmat endorsement on a CDL if he or she is wanted or under indictment in any civilian or military jurisdiction for a felony listed under Part A or Part B until the want or warrant is released. Section 2. Permissible Immigration Status to Hold Hazardous Materials Endorsement An applicant for an HME must be one of the following: • A citizen of the U.S. who has not renounced his/her U.S. citizenship • A lawful permanent resident of the U.S. as defined in section 101(a)(20) of the Immigration and Nationality Act (8 U.S.C. 1101) • A lawful nonimmigrant in possession of valid, unrestricted employment authorization • A refugee admitted under section 8 U.S.C. 1157 in possession of valid unrestricted employment authorization • In asylum status under section 8 U.S.C. 1158 in possession of valid, unrestricted employment authorization Section 3. Privacy Act and Paperwork Reduction Act Notices Privacy Act Notice: The authority for collecting this information is 49 U.S.C. 114, 40113 and 49 U.S.C. 5103a. Purpose: This information is needed to verify your identity and to conduct a security threat assessment to evaluate your suitability for a hazardous materials endorsement for a commercial driver’s license. Your Social Security Number (SSN) or alien registration number will be used as your identification number in this process and to verify your identity. Furnishing this information, including your SSN or alien registration number, is voluntary; however, failure to provide it will prevent the completion of your security threat assessment, without which you may not be granted a hazardous materials endorsement. Routine Uses: Routine uses of this information include disclosure to the FBI to retrieve your criminal history record; to TSA contractors or other agents who are providing services relating to the security threat assessment to appropriate governmental agencies for licensing, law enforcement, or security purposes, or in the interests of national security; and to foreign and international governmental authorities in accordance with law and international agreement. Apply to register to vote with your driver’s license transaction. For details ask your customer service representative. American LegalNet, Inc. www.FormsWorkFlow.com