WisDOT Employees ONLY: Email form with any YES answers to: dmed@dot.wi.gov. Forms with only NO answers can be scanned into the system under document type MV3740. Please print Applicant Name First Middle Initial Last Birth Date (m/d/yyyy) – Wisconsin Driver License Number or Social Security Number For Verification Purposes – YES NO Have you ever been convicted of a crime or other offense listed under s.343.12(7) Wis. Stats. or Ch. Trans. 112.15 WI Admin. Code within the time frame listed on ply 1 of this form? Are you currently listed on any sex offender registry? Are you currently listed on any nurse abuse registry? Explain answers “YES” YES NO Have you been a resident in another state within the previous 2 years? If you checked list all state(s) in which you have been a resident during the previous “YES”, 2 years. States: APPLICANT STATEMENTS With issuance of a Wisconsin School Bus License or as an alternative vehicle driver, I agree to report in writing to my employer, within 10 days: Any accident in which I was involved as the operator of any motor vehicle regardless of who was at fault or if citations were issued; Any conviction or operating privilege withdrawal listed under s.343.12(7) Wis. Stats. or Ch. Trans. 112.15 WI Admin. Code that makes the operator ineligible to operate a motor vehicle to transport pupils; If I hold a school bus endorsement, any incidents that would disqualify me for holding that endorsement; Any suspension or revocation of my operating privilege; Any cancellation of my school bus endorsement by this state or another jurisdiction. I understand that I may not falsify or provide incomplete information in respect to any material fact on this or any other background information form. I also understand that it is my responsibility to report any new medical condition or a medical condition that has significantly changed since my last report. X (Applicant Signature) (Date m/d/yyyy) – For WisDOT/Employer USE ONLY Please check one – Original Application Interim CIB Check Renewal CCAP Check Electronic form: Fill out, print, and make desired copies. form: White WisDOT, Pink Employer – –
Please print WisDOT Employees ONLY: Email form with any YES answers to: dmed@dot.wi.gov. Forms with only NO answers can be scanned into the system under document type MV3740. Applicant Name – First Middle Initial Last Birth Date (m/d/yyyy) Wisconsin Driver License Number or Social Security Number – For Verification Purposes YES NO Have you ever been convicted of a crime or other offense listed under s.343.12(7) Wis. Stats. or Ch. Trans. 112.15 WI Admin. Code within the time frame listed on ply 1 of this form? Are you currently listed on any sex offender registry? Are you currently listed on any nurse abuse registry? Explain “YES” answers YES NO Have you been a resident in another state within the previous 2 years? If you checked “YES”, list all state(s) in which you have been a resident during the previous 2 years. States: APPLICANT STATEMENTS With issuance of a Wisconsin School Bus License or as an alternative vehicle driver, I agree to report in writing to my employer, within 10 days: Any accident in which I was involved as the operator of any motor vehicle regardless of who was at fault or if citations were issued; Any conviction or operating privilege withdrawal listed under s.343.12(7) Wis. Stats. or Ch. Trans. 112.15 WI Admin. Code that makes the operator ineligible to operate a motor vehicle to transport pupils; If I hold a school bus endorsement, any incidents that would disqualify me for holding that endorsement; Any suspension or revocation of my operating privilege; Any cancellation of my school bus endorsement by this state or another jurisdiction. I understand that I may not falsify or provide incomplete information in respect to any material fact on this or any other background information form. I also understand that it is my responsibility to report any new medical condition or a medical condition that has significantly changed since my last report. X (Applicant Signature) (Date – m/d/yyyy) For WisDOT/Employer USE ONLY – Please check one Original Application Renewal Interim CIB Check CCAP Check Electronic form: Fill out, print, and make desired copies. form: White – WisDOT, Pink – Employer
mv3740.docx