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Fillable Printable Form 5140 - Missouri Department Of Revenue

Fillable Printable Form 5140 - Missouri Department Of Revenue

Form 5140 - Missouri Department Of Revenue

Form 5140 - Missouri Department Of Revenue

During the two years before today’s date:
Have you had more than one license (except for a military license)? ............................................. r Yes r No
Has your license been suspended, revoked, cancelled, or disqualified in this or any other state? ....................... r Yes r No
Have you been convicted of causing a fatality through the negligent operation of a commercial motor vehicle? ............ r Yes r No
Have you been convicted of using any vehicle in the commission of a felony involving the manufacturing, distributing,
or dispensing of a controlled substance? ................................................................... r Yes r No
Have you been convicted of driving a commercial motor vehicle without a commercial license? ........................ r Yes r No
Have you been convicted of driving a commercial motor vehicle without a commercial license in your possession? ........ r Yes r No
Have you been convicted of driving a commercial motor vehicle without the proper class or endorsements for a specific CDL
group being operated or for the passengers or type of cargo being transported? .................................... r Yes r No
Have you been convicted of driving a commercial motor vehicle while using a hand-held mobile phone? . . . . . . . . . . . . . . . . . r Yes r No
Have you been convicted of driving a commercial motor vehicle while texting? ..................................... r Yes r No
Have you been convicted of driving while intoxicated or driving while under the influence of alcohol (includes BAC)? ....... r Yes r No
Have you been convicted of driving while under a controlled substance or refusal to submit to an alcohol test? ........... r Yes r No
Have you been convicted of leaving the scene of an accident? ................................................. r Yes r No
Have you been convicted of a felony involving a motor vehicle? ................................................. r Yes r No
Have you been convicted of speeding 15 or more MPH over the posted speed limit? ................................ r Yes r No
Have you been convicted of careless and imprudent driving? ................................................... r Yes r No
Have you been convicted of following too closely? ........................................................... r Yes r No
Have you been convicted of improper lane change? .......................................................... r Yes r No
Have you been convicted of a violation in connection with a fatal accident? ........................................ r Yes r No
Have you been convicted of any military, state law or county or municipal ordinance relating to the operation of any type
of motor vehicle in connection with an accident? ............................................................. r Yes r No
Have you had more than one conviction for any type of motor vehicle for serious traffic violations? ..................... r Yes r No
Missouri Department of Revenue
Application for Military Commercial
Driver License (CDL) Skills Test Waiver
Name (Last, First, and Middle) Driver License Number
Residence A
ddress (Street) City State Zip Code County
Mailing Address (If Different) City State Zip Code County
Form 5140 (Revised 07-2016)
Form
5140
This form may be used by qualified active duty or retired military applicants. This waiver allows a qualified military applicant to apply for a Commercial Driver
License (CDL) without skills testing. CDL knowledge (written) test(s) are not waived and must be submitted to the license office along with this application.
Applicant
Information
Driver Record CertificationDriving Experience
Have you been regularly employed in the last 90 days in a job requiring operation of a military motor vehicle and have operated
the vehicle for at least sixty days during the two years immediately preceding this application for a commercial driver license? r Yes r No
Is the military vehicle you have operated representative of the commercial motor vehicle you currently operate or expect to
operate? .............................................................................................. r Yes r No
Select one that applies:
r I have been honorably discharged from military service. I am providing proof of military service (a copy of Form DD214); and a copy of my military
driving record.
r I am an active duty member of the Armed Forces. I am providing a notarized statement specifying the types of commercial vehicles I am qualified to
operate completed by my commanding officer on the reverse of this form; and a copy of my military driving record.
Applicant’s Signature Title
Printed Name Date (MM/DD/YYYY)
Signature
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
__ __ /__ __ /__ __ __ __
Reset Form
Print Form
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Example Of Vehicles In Group
Class
r A
r A
r B
Commanding Officer’s Name (Last, First, and Middle) Telephone Number
Residence A
ddress (Street) City State Zip Code County
Mail to: Driver License Bureau Phone: (573) 526-2407
P.O. Box 200 Fax: (573) 522-8174
Jefferson City, MO 65105-0200 E-mail: [email protected]
Visit http://www.dor.mo.gov/drivers/ for
additional information.
Form 5140 (Revised 07-2016)
Commanding Officer’s Signature (must be notarized) Title
Printed Name Date (MM/DD/YYYY)
Signature
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
__ __ /__ __ /__ __ __ __
Notary Information
Subscribed and sworn before me, this
day of year
State County (or City of St. Louis) My Commission Expires (MM/DD/YYYY)
Notary Public Signature
Notary Public Name (Typed or Printed)
Embosser or black ink rubber stamp seal
__ __ /__ __ /__ __ __ __
Driving Experience Certification
Vehicle Description
* 5th Wheel - Truck Tractor or Semitrailer
Any combination of vehicles with a GCWR of 26,001 or
more pounds provided the GVWR of the vehicle(s) being
towed is in excess of 10,000 pounds.
* Pintle Hook - Truck Trailer Combination
Any combination of vehicles with a GCWR of 26,001 or
more pounds provided the GVWR of the vehicle(s) being
towed is in excess of 10,000 pounds.
Any single vehicle with a GVWR of 26,001 or more pounds
or any such vehicle towing a vehicle not in excess of 10,000
pounds GVWR.
I hereby certify the applicant on this form is an active duty member of the Armed Forces and has been employed in a military position within the past 90
days requiring operation of a military motor vehicle and operated the following commercial class vehicles a minimum of sixty days within the two years
prior to this application.
Select the boxe(s) below for the class(es) of vehicle operated.
The remainder of this form is to be completed by your commanding ofcer and notarized.
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