Form DSD CB-1.2 "Charter Bus Application/Certification" - Illinois

What Is Form DSD CB-1.2?

This is a legal form that was released by the Illinois Secretary of State - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2006;
  • The latest edition provided by the Illinois Secretary of State;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DSD CB-1.2 by clicking the link below or browse more documents and templates provided by the Illinois Secretary of State.

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Download Form DSD CB-1.2 "Charter Bus Application/Certification" - Illinois

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Illinois Secretary of State
CHARTER BUS APPLICATION/CERTIFICATION
Applicant Information (To be completed by the applicant)
______________________________________________________________________________________
Last Name
First Name
M.I.
______________________________________________________________________________________
Street Address
City
State
ZIP
Driver’s License Number ________________________________________________________________
Employer Number _____________________________________________________________________
__________________________
Social Security Number ____________________________ Date of Birth _________________________
Under penalty of perjury, I swear and affirm that I have not been convicted of any criminal or traffic
offenses that would disqualify me from driving a charter bus or made a false statement or knowingly con-
cealed a material fact in this application for a charter bus driver endorsement, and that I comply with all
provisions of Sections 6-104 and 6-508 of the Illinois Vehicle Code. I hereby consent and certify that the
information contained in this document is true. I hereby consent to the release by the Secretary of State of
fingerprint information to my employer.
________________________________________
_______________________________________
Applicant Signature
Date
__________________________
New Applicant (To be completed by the employer)
All requirements in this section must be completed by marking each box and providing the date of
completion before an applicant will be allowed to obtain a charter bus driver endorsement at a facility.
Age 21 or older.
Completed a Medical Examination, including chemical testing for drugs.
Medical Examination valid through _____________________________________________________.
Date
Illinois specific criminal background investigation successfully completed by Illinois State Police
showing no offenses as set forth in Section 6-508 (C-1)(1)(4) of the Illinois Vehicle Code [625 ILCS 5/
__________________________
6-508]. Date employer received this notification ___________________________________.
Printed by authority of the State of Illinois. January 2006 – DSD CB-1.2
Illinois Secretary of State
CHARTER BUS APPLICATION/CERTIFICATION
Applicant Information (To be completed by the applicant)
______________________________________________________________________________________
Last Name
First Name
M.I.
______________________________________________________________________________________
Street Address
City
State
ZIP
Driver’s License Number ________________________________________________________________
Employer Number _____________________________________________________________________
__________________________
Social Security Number ____________________________ Date of Birth _________________________
Under penalty of perjury, I swear and affirm that I have not been convicted of any criminal or traffic
offenses that would disqualify me from driving a charter bus or made a false statement or knowingly con-
cealed a material fact in this application for a charter bus driver endorsement, and that I comply with all
provisions of Sections 6-104 and 6-508 of the Illinois Vehicle Code. I hereby consent and certify that the
information contained in this document is true. I hereby consent to the release by the Secretary of State of
fingerprint information to my employer.
________________________________________
_______________________________________
Applicant Signature
Date
__________________________
New Applicant (To be completed by the employer)
All requirements in this section must be completed by marking each box and providing the date of
completion before an applicant will be allowed to obtain a charter bus driver endorsement at a facility.
Age 21 or older.
Completed a Medical Examination, including chemical testing for drugs.
Medical Examination valid through _____________________________________________________.
Date
Illinois specific criminal background investigation successfully completed by Illinois State Police
showing no offenses as set forth in Section 6-508 (C-1)(1)(4) of the Illinois Vehicle Code [625 ILCS 5/
__________________________
6-508]. Date employer received this notification ___________________________________.
Printed by authority of the State of Illinois. January 2006 – DSD CB-1.2
Reapplicant (To be completed by the employer)
This section must be completed by marking the box and indicating the date the examination is valid
through before an applicant will be allowed to retain a charter bus driver endorsement at a facility.
Completed a D.O.T. Medical Examination, including chemical testing for drugs.
Medical Examination valid through _____________________________________________________.
Date
NOTE TO EMPLOYER: Reapplicants (within 30 days subsequent to the expiration of a license) are not
required to be refingerprinted.
__________________________
Certification
Under penalty of perjury, I swear and affirm that the applicant meets all requirements in accordance with
Sections 6-104 and 6-508 of the Illinois Vehicle Code [625 ILCS 5/6-104 and 5/6-508].
________________________________________
_______________________________________
Date
Signature of Employer/Designee
________________________________________
_______________________________________
Secretary of State Assigned Employer #
Employer Name
________________________________________
_______________________________________
Employer Telephone Number
Employer Address
_______________________________________
NOTE TO EMPLOYER: It is the responsibility of a prospective, current or previous employer to maintain
records of certifications and all verifications on the premises, which would be available for immediate
inspection by the Secretary of State.
__________________________
Secretary of State Facility Use Only
Is this applicant in compliance with the requirements of Sections 6-104 and 6-508 of the Illinois Vehicle
Code?
Yes
No
_____________________________________________________________
__________________________
Facility Representative Signature/Employee Number
Printed by authority of the State of Illinois. January 2006 – DSD CB-1.2
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