Fillable Printable Form HAZ-44 - Application for a Hazardous Materials Endorsement - New York

Form HAZ-44 - Application for a Hazardous Materials Endorsement - New York

I am applying for a :

Combination HazMat & Tanker

HazMat

New York State Department of Motor Vehicles

APPLICATION FOR A HAZARDOUS MATERIALS ENDORSEMENT

Male Female

PLEASE PRINT CLEARLY

LAST NAME

FIRST NAME

MIDDLE NAME SUFFIX

PREVIOUS NAME USED (if any): LAST NAME FIRST NAME

MIDDLE NAME

COUNTRY OF CITIZENSHIP

ALIEN REGISTRATION NO. (if you are a legal alien or a naturalized citizen)

SUFFIX

WEIGHT (LBS) SEXHEIGHTEYE COLOR

HAIR COLOR

PAGE 1 OF 2

Month Day Year

DATE OF BIRTH

Month Day Year

NATURALIZATION DATE (if applicable)

TYPE OF APPLICATION

If transferring, list prior CDL

number & state of issuance

ADDRESS WHERE YOU GET YOUR MAIL

- Include Street Number and Name, Rural Delivery and/or box number, or PO box number

ADDRESS WHERE YOU LIVE

Apt. No. City or Town State Zip Code

CDL Number (if available)

- IF DIFFERENT FROM MAILING ADDRESS (DO NOT GIVE P.O. BOX NUMBER)

Feet Inches

License ID No:

Apt. No. City or Town State Zip Code

PREVIOUS ADDRESS WHERE YOU LIVED (DO NOT GIVE P.O. BOX NUMBER)

Home Phone (Include area code)

( )

Work Phone (Include area code)

( )

Cell Phone (Include area code)

( )

E-Mail Address

Country of Birth (for example: USA, Canada, Mexico)

City of Birth State of Birth (Not required if born outside the U.S.)

Apt. No. City or Town State Zip Code

Country

This form is also available on DMV’s web site at: www.dmv.ny.gov

The federal Transportation Security Administration requires all drivers who are applying for a hazardous materials endorsement to complete and sign

this form. Be sure to provide all information requested on

pages 1 and 2. Mail the completed application and a copy of your legal status

document(s) to HazMat Unit, NYS DMV, 6 Empire State Plaza, Albany, NY 12228.

o New o Renewal o Transfer

Are you a U.S. Citizen?

o Yes o No

If born abroad to U.S. citizens, check the State Department Form Number

and

provide number assigned: __________________________________

Legal Status Document Type

(see list below)

Assigned Number Expiration Date (if applicable)

ADDRESS OF YOUR CURRENT EMPLOYER

City or Town

1. Have you undergone or are you undergoing a DHS

(including TSA) security threat assessment?

2. Have you had or do you have a DHS/TSA credential (e.g.,

Aviation Worker, Certified Cargo Screening, Indirect Air

Carrier, TWIC, FAST, MMD, etc.)?

If yes: Name of program (e.g., Aviation Worker, Certified Cargo Screening, Indirect Air

Carrier, TWIC, FAST, MMD, etc.):____________________________________________

If yes: Type of credential: _________________________________________________

Credential reference number: ______________________________________________

EMPLOYER’S PHONE NO.

Area Code

( )

NAME OF YOUR CURRENT EMPLOYER

ACCEPTABLE DOCUMENTS FOR PROOF OF LEGAL STATUS

u U.S. Passport (not expired)

u Certified copy of a birth certificate filed with a State Office of Vital Statistics or

equivalent agency in the applicant’s state of birth, Puerto Rico, Virgin Islands, Guam,

American Samoa, or the Commonwealth of the Northern Mariana Islands

u Consular Report of Birth Abroad issued by the U.S. Department of State

(Form FS-545 or DS-1350)

u Certificate of Naturalization issued by the U.S. Department of Homeland

Security (Form N-550 or N-570)

u Certificate of Citizenship issued by the U.S. Department of Homeland

Security (Form N-560 or N-561)

w Permanent Resident Card (not expired) issued by USCIS or INS (Form I-551)

HAZ-44 (2/13)

State

SECTION I - PERSONAL INFORMATION

SECTION II - ADDRESSES

SECTION III - CITIZENSHIP

SECTION IV - EMPLOYMENT HISTORY

o Yes o No

o FS-240 oFS-545 oDS-1350

State Zip Code Country

I certify that I meet the federal medical requirements

in 49CFR Part 391 and that I have a valid USDOT

Medical Examiner’s Certificate.

NOTE: If you cannot answer YES or you do not have a valid

Medical Examiner’s Certificate, do not complete this application

because you are not eligible for a HazMat endorsement.

Yes

Federal Disqualifying Criminal Offenses for Hazardous Materials Endorsement

Part B: Interim Disqualifying Offenses

A driver will be disqualified from holding a hazmat endorsement if he or she was convicted (or found not guilty by reason of insanity) within

the previous seven years, or was released from prison in the last five years, for any of the following felonies:

Part A: Permanently Disqualifying Criminal Offenses

Part C: Under Want or Warrant

Part D: Read each statement below, then check the appropriate box.

PAGE 2 OF 2

A driver will be permanently disqualified from holding a hazmat endorsement if he or she was convicted (or found not guilty by reason of

insanity) for any of the following felonies:

a) Espionage

b) Sedition

c) Treason

d) A federal crime of terrorism as defined in 18 U.S.C. 2332b(g),

or a state law that is comparable

e) A crime involving a transportation security incident

f) Improper transportation of a hazardous material under

49 U.S.C. 5124 or a state law that is comparable

g) Unlawful possession, use, sale, distribution, manufacture,

purchase, receipt, transfer, shipping, transporting, import, export,

storage of, or dealing in an explosive or explosive device

h) Murder

i) Making any threat, or maliciously conveying false information

knowing the same to be false, concerning the deliverance,

placement, or detonating of an explosive or other lethal device

in or against a place of public use, a state or government facility,

a public transportation system, or an infrastructure facility.

j) Violations of the Racketeer Influenced and Corrupt Organizations

Act, 18 U.S.C. 1961, et seq., or a state law that is comparable,

where one of the predicate acts found by a jury or admitted by the

defendant, consists of one of the offenses listed in this section

k) Conspiracy or attempt to commit any of these crimes

1. Have you been convicted, or found not guilty by reason of insanity, of any disqualifying crime listed in Part A,

in any jurisdiction, military or civilian, during the 7 years before the date of this application?

A driver will be disqualified from holding a hazmat endorsement if he or she is wanted or under indictment in any civilian or military

jurisdiction for a felony listed under Part A or Part B, until the want or warrant is released.

NOTE: New York State’s standards for disqualification are more stringent than the federal standards. Refer to NYS DMV form HAZ-11 for

more information.

a) Unlawful possession, use, sale, manufacture, purchase,

distribution, receipt, transfer, shipping, transporting, delivery,

import, export of, or dealing in a firearm or other weapon

b) Extortion

c) Dishonesty, fraud, or misrepresentation, including identity fraud

d) Bribery

e) Smuggling

f) Immigration violations

g) Distribution of, intent to distribute, or importation of a controlled

substance

h) Arson

i) Kidnapping or hostage taking

j) Rape or aggravated sexual abuse

k) Assault with intent to murder

l) Robbery

m) Fraudulent entry into a seaport as described in 18 U.S.C. 1036,

or a comparable State law

n) Violations of the Racketeer Influenced and Corrupt

Organizations Act, 18 U.S.C. 1961, et seq., or a state law that is

comparable, other than the violations listed in item (j) of Part A

above (“Permanently Disqualifying Criminal Offenses”)

o) Conspiracy or attempt to commit any of these crimes

READ THE INFORMATION AND ANSWER THE QUESTIONS ABOVE BEFORE SIGNING BELOW.

CERTIFICATION: I have disclosed any and all information with this application related to disqualifying crimes committed, as required by

federal regulation 49 CFR 1572.5(b). I understand my continuing obligation to disclose to TSA within 24 hours if I am convicted or found

not guilty by reason of insanity of any disqualifying crime, or if I am adjudicated as a mental defective or committed to a mental institution,

while I have a hazardous materials endorsement for a CDL. The information I have provided on this application is true, complete and

correct to the best of my knowledge and belief, and is provided in good faith. I understand that a knowing and willful false statement, or an

omission of a material fact, on this application can be punished by fine or imprisonment or both (see section 1001 of Title 18 United States

Code), and may be grounds for denial of a hazardous materials endorsement.

SIGN HERE ç______________________________________________________________ DATE _____________________

HAZ-44 (2/13)

£ Yes £ No

2. Have you been released from incarceration in any jurisdiction, military or civilian, for committing any

disqualifying crime listed in Part A, during the 5 years before the date of this application?

Yes

3. Have you been convicted, or found not guilty by reason of insanity, of any disqualifying crime listed in Part B,

in any jurisdiction, military or civilian?

Yes

4. Are you wanted or under indictment for any disqualifying crime listed in Part C?

Yes

5. Have you ever been adjudicated as lacking mental capacity, or involuntarily committed to a mental institution?

Yes