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Name __________________________________________ Social Security # ________________________________

I certify that I have been employed by the following employers during the two years prior to the date stated below and that I was required to possess a commercial driver’s license (CDL) during the term of my employment.

Company Phone
Address
City/State/Zip
Company Phone
Address
City/State/Zip
Company Phone
Address
City/State/Zip
Company Phone
Address
City/State/Zip
Company Phone
Address
City/State/Zip
Signature __________________________________________ Date ________________________________