Form SFN16275 "Application for a North Dakota Seasonal License" - North Dakota

Form SFN16275 or the "Application For A North Dakota Seasonal License" is a form issued by the North Dakota Department of Transportation.

The form was last revised in October 5, 2018 and is available for digital filing. Download an up-to-date Form SFN16275 in PDF-format down below or look it up on the North Dakota Department of Transportation Forms website.

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Download Form SFN16275 "Application for a North Dakota Seasonal License" - North Dakota

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APPLICATION FOR A NORTH DAKOTA SEASONAL LICENSE
North Dakota Department of Transportation, Drivers License
SFN 16275 (10-2018)
DLN
Select One (See reverse side)
Name of Driver (Last, First & Middle)
Seasonal Issue Start Date
90 Day
180 Day
Mailing Address
City
State
ZIP Code
Telephone Number
Social Security Number
Date of Birth
A. DRIVER RECORDS CERTIFICATION
I certify under penalty of law that I currently am and have been a licensed North Dakota driver for one or more years, I am an
employee in the agri-business service industry, and within the past two years:
I have not had more than one license valid at the same time.
I have not had my driving privileges suspended, revoked, or canceled.
I have not been convicted of any serious traffic violations or any disqualifying offenses contained in 49 CFR 383.51(b) & (c).
I have not had any conviction for a violation of state or local law relating to motor vehicle traffic control (other than a parking violation)
arising in connection with any traffic accident and no record of an at-fault accident.
B. PHYSICAL CERTIFICATION
1. Do you have a physical or medical condition?
Yes
No
If yes, list condition and date of diagnosis: _______________________________________________
2. Do you have a history of epliepsy, blackout attacks, or other lapse of consciousness?
Yes
No
If yes, give date of last episode: _______________________________________________________
3. Do you have a diabetic condition requiring insulin for control?
Yes
No
4. Do you have a heart condition?
Yes
No
If yes, explain: _____________________________________________________________________
5. Have you ever been adjudged incompetent or been disabled due to a mental illness?
Yes
No
If yes, explain: _____________________________________________________________________
Yes
No
6. Do you habitually use alcoholic beverages or narcotic drugs to excess?
C. VISUAL CERTIFICATION
Vision screening must be completed by a driver examiner, physician, or optometrist. (See Reverse Side)
D. COMMERCIAL MEDICAL CERTIFICATION (DOT CARD)
You must check one of the following:
Medical Certificate must be carried by the driver in both cases.
I certify my commercial transportation is Intrastate (do not cross state lines). Do not attach medical certificate.
I certify my commercial transportation is Interstate (crosses state lines). Must attach copy of medical certificate.
E. APPLICANT SIGNATURE AND DATE
Applicant Signature
Date
F. Notary Public Signature/Seal
I certify under penalty of law the company listed is the employer of the employee listed.
Company Name
Employee Name
Employer Email Address
Employer Signature
STATE OF NORTH DAKOTA)
COUNTY OF __________________________)ss
Subscribed and sworn to before me this ___________day of ____________________________, 20_______
Notary Public: ______________________________
(SEAL)
My commission expires: ______________________
FEDERAL PRIVACY ACT OF 1974
Disclosure of the individual's social security number on this form is mandatory pursuant to NDCC 39-06-07. The individual's social security number is
used by the Department for file control purposes and record keeping.
APPLICATION FOR A NORTH DAKOTA SEASONAL LICENSE
North Dakota Department of Transportation, Drivers License
SFN 16275 (10-2018)
DLN
Select One (See reverse side)
Name of Driver (Last, First & Middle)
Seasonal Issue Start Date
90 Day
180 Day
Mailing Address
City
State
ZIP Code
Telephone Number
Social Security Number
Date of Birth
A. DRIVER RECORDS CERTIFICATION
I certify under penalty of law that I currently am and have been a licensed North Dakota driver for one or more years, I am an
employee in the agri-business service industry, and within the past two years:
I have not had more than one license valid at the same time.
I have not had my driving privileges suspended, revoked, or canceled.
I have not been convicted of any serious traffic violations or any disqualifying offenses contained in 49 CFR 383.51(b) & (c).
I have not had any conviction for a violation of state or local law relating to motor vehicle traffic control (other than a parking violation)
arising in connection with any traffic accident and no record of an at-fault accident.
B. PHYSICAL CERTIFICATION
1. Do you have a physical or medical condition?
Yes
No
If yes, list condition and date of diagnosis: _______________________________________________
2. Do you have a history of epliepsy, blackout attacks, or other lapse of consciousness?
Yes
No
If yes, give date of last episode: _______________________________________________________
3. Do you have a diabetic condition requiring insulin for control?
Yes
No
4. Do you have a heart condition?
Yes
No
If yes, explain: _____________________________________________________________________
5. Have you ever been adjudged incompetent or been disabled due to a mental illness?
Yes
No
If yes, explain: _____________________________________________________________________
Yes
No
6. Do you habitually use alcoholic beverages or narcotic drugs to excess?
C. VISUAL CERTIFICATION
Vision screening must be completed by a driver examiner, physician, or optometrist. (See Reverse Side)
D. COMMERCIAL MEDICAL CERTIFICATION (DOT CARD)
You must check one of the following:
Medical Certificate must be carried by the driver in both cases.
I certify my commercial transportation is Intrastate (do not cross state lines). Do not attach medical certificate.
I certify my commercial transportation is Interstate (crosses state lines). Must attach copy of medical certificate.
E. APPLICANT SIGNATURE AND DATE
Applicant Signature
Date
F. Notary Public Signature/Seal
I certify under penalty of law the company listed is the employer of the employee listed.
Company Name
Employee Name
Employer Email Address
Employer Signature
STATE OF NORTH DAKOTA)
COUNTY OF __________________________)ss
Subscribed and sworn to before me this ___________day of ____________________________, 20_______
Notary Public: ______________________________
(SEAL)
My commission expires: ______________________
FEDERAL PRIVACY ACT OF 1974
Disclosure of the individual's social security number on this form is mandatory pursuant to NDCC 39-06-07. The individual's social security number is
used by the Department for file control purposes and record keeping.
SFN 16275 (10-2018)
Page 2 of 2
VISION EXAMINATION
This certificate of examination must be completed by a physician, optometrist, or driver examiner. This statement must give the
corrected and uncorrected vision of the applicant, field of vision and ability to distinguish colors.
Vision results cannot be older than 6 months.
Field of Vision in Degrees (Requires Numbers)
ACUITY VISION
RIGHT EYE
LEFT EYE
BOTH EYES
Left Eye
Right Eye
Actual Vision Without
20/
20/
20/
Temporal
Temporal
Correction
Vision Corrected To
20/
20/
20/
Nasal
Nasal
Yes
No
Does the applicant have the ability to distinguish the colors red, green, and amber?
Comments
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Signature of Eye Specialist/Examiner
Date
Address
Business Telephone Number
IMPORTANT INFORMATION
Only one 180 day or two 90 day seasonal licenses will be issued in a 12 month period.
Please indicate your choice on the front of the application and write in the date you want your seasonal license to be processed at
the central Office.
A new application and $15 fee is required each time a seasonal license is issued.
Note: The 90 day option provides the opportunity to meet two 'seasonal' periods within the 12 month timeframe. No fee or vision
exam is required for the second 90 day seasonal license.
Check Box if this is your second 90 day seasonal license within the current 12 month timeframe.
Only employees eighteen years of age or older are eligible for a restricted seasonal drivers license. Waiver authorization pursuant
to 49 CFR 383.3. The restrictions and limitations are described below.
Seasonal CDL class code - Class B or C - any single vehicle (or any such vehicle towing a trailer 10,000 pounds GVWR or less.)
Not valid for class A or M vehicle group. Not valid for passenger bus designed to transport 16 or more passengers including the
driver.
Seasonal CDL Restrictions "W"
* May operate Class B or C vehicle groups within 150 miles from place of business or farm being served.
* May transport farm agricultural products, farm machinery, and supplies.
* Limited to transporting the following placarded hazardous materials:
- Diesel fuel of 1,000 gallons or less
- Liquid fertilizer in vehicles with a total capacity of 3,000 gallons or less
- Solid fertilizers that are not mixed with any organic substance
DRIVERS LICENSE DIVISION
Mail application and $15 commercial license fee to:
608 E BOULEVARD AVE
BISMARCK ND 58505-0750
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