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Get KS Escort Cert App 2010

ESCORT CERTIFICATION APPLICATION CENTRAL PERMITS New Certification Assigned by Central Permits MAILING ADDRESS Past Certification If recertifying CONTACTS Expiration Date CUSTOMER INFORMATION Central Permits Phone 785-368-6501 Company Name Docking State Office Building Fax 785-296-6558 Company Address 915 SW Harrison Room 150 Topeka Kansas 66612 State City Email mc kdor. State. ks. us Zip Drivers Name KANSAS CERTIFICATIONS Defensive Driving course or Valid CDL Must provide evidence of taking the driving course or copy of the CDL upon application Length of Certification 3 Years ALTERNATE CERTIFICATION Without a CDL or have previously taken a Defensive driving course state certifications will be accepted for one year only. Course or obtain a valid CDL Documentation shall be provided to Central Permits I I certify that I am employed by the above named company or meet all the requirements and have obtained all the necessary credentials in order to operate as a self-employed escort driver. state. ks. us Zip Drivers Name KANSAS CERTIFICATIONS Defensive Driving course or Valid CDL Must provide evidence of taking the driving course or copy of the CDL upon application Length of Certification 3 Years ALTERNATE CERTIFICATION Without a CDL or have previously taken a Defensive driving course state certifications will be accepted for one year only. Course or obtain a valid CDL Documentation shall be provided to Central Permits I I certify that I am employed by the above named company or meet all the requirements and have obtained all the necessary credentials in order to operate as a self-employed escort driver. I further certify I possess a current drivers license or CDL SIGNATURES Print Name Signature of Escort Driver Signature of Central Permits Official Dt00mh82 internet www. ksdot. org bureaus burTrafficEng KTC doc EscortCertificationApplication*doc Date Revised 10/28/2010. Course or obtain a valid CDL Documentation shall be provided to Central Permits I I certify that I am employed by the above named company or meet all the requirements and have obtained all the necessary credentials in order to operate as a self-employed escort driver. I further certify I possess a current drivers license or CDL SIGNATURES Print Name Signature of Escort Driver Signature of Central Permits Official Dt00mh82 internet www. I further certify I possess a current drivers license or CDL SIGNATURES Print Name Signature of Escort Driver Signature of Central Permits Official Dt00mh82 internet www. ksdot. org bureaus burTrafficEng KTC doc EscortCertificationApplication*doc Date Revised 10/28/2010. Course or obtain a valid CDL Documentation shall be provided to Central Permits I I certify that I am employed by the above named company or meet all the requirements and have obtained all the necessary credentials in order to operate as a self-employed escort driver. I further certify I possess a current drivers license or CDL SIGNATURES Print Name Signature of Escort Driver Signature of Central Permits Official Dt00mh82 internet www. ksdot. org bureaus burTrafficEng KTC doc EscortCertificationApplication*doc Date Revised 10/28/2010. .

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