Maryland > Statewide > Motor Vehicle Administration
Hazardous Materials Endorsement Application DL-192 - Maryland
| Hazardous Materials Endorsement Application Form. This is a Maryland form and can be used in Motor Vehicle Administration Statewide . |
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Motor Vehicle Administration 6601 Ritchie Highway, N.E. Glen Burnie, Maryland 21062 DL-192 (1-05) Maryland Hazardous Materials Endorsement Application Shaded area for Department use only State CDL was issued (SOR): Printed Last Name MARYLAND First Name MD Driver's License # Middle Name Suffix Printed Last Name (AKA or Alias) First Name (AKA or Alias) Middle Name (AKA or Alias) Suffix (AKA or Alias) Social Security Number Telephone No. (With Area Code) Endorsement Type Hazmat Hazmat/Tanker Combined Eye Male Female Color: Black Blue Brown Dichromatic Grey Green Hazel Maroon Pink Height (ft. and in.) Weight (lbs.) Hair Color: Bald Black Blond Brown Gray Red/Auburn Sandy White Residence Street Address Mailing Address (if Different) City City State/Province Zip/Postal Code State Zip Code Country Sex Date of Birth City of Birth State of Birth Country of Birth Country of Citizenship Naturalization Date (if Naturalized US Citizen) Alien Registration No. (If Lawful Permanent US Resident) U.S. Military Service? Yes No If Yes, Which Branch?: Air Force Army Navy Marine Coast Guard Merchant Marine National Guard City State/Province Discharge Date Dishonorable Discharge Yes No Country Previous Residence Address Residence Street Address Zip/Postal Code Current Employer Name Telephone No. (including Area Code) Current Employer Street Address City or Municipality State/Province Zip/Postal Code Country Current Employer Name (If More Than One) Telephone No. (Including Area Code) Current Employer Street Address (If More Than One) City or Municipality State/Province Zip/Postal Code Country Answer the following questions by checking the appropriate box 1. Have you been convicted or found not guilty by reason of insanity of any disqualifying crime listed in Section 1, Part A, in any jurisdiction, civilian or military, during the seven years before the date of this application? ............................. Yes No 2. Have you been released from incarceration in any jurisdiction, civilian or military, for committing any disqualifying crime listed in Section 1. Part A, during the five years before the date of this application? .................................................... Yes No 3. Have you been convicted or found not guilty by reason of insanity of any disqualifying crime listed in Section 1. Part B, in any jurisdiction, civilian or military? ........................................................................................................ Yes No 4. Are you wanted or under indictment in any jurisdiction, civilian or military, of any disqualifying crime listed in Section 1? .... Yes No 5. Have you been adjudicated as lacking mental capacity or committed to a mental institution involuntarily? ........................... Yes No 6. Do you meet the eligibility requirements for immigration status? (See Section 2) .................................................................. Yes No I, the undersigned, have been informed that Federal regulations under 49 CFR 1572.11(c) impose a continuing obligation to disclose to the Transportation Security Administration (TSA) within 24 hours if I am convicted of, wanted, under indictment, or found not guilty by reason of insanity of any disqualifying crime, or adjudicated as lacking mental capacity or committed to a mental institution, renounce or lose my U.S. citizenship, or violate my immigration status and/or am ordered removed from the U.S. 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. Applicant's Signature Date Signed Location Signed Witnessed By (Licensing Representative) Date Signed For more information, please call: 1-800-638-8347 (touch tone calls only), 1-800-950-1MVA (1682) (to speak with a customer service representative), From Out-of-State: 1-301-729-4550, TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.marylandmva.com American LegalNet, Inc. www.FormsWorkFlow.com Section 1. List of Disqualifying Criminal Offenses for Hazardous Materials Endorsement Part A. Interim Disqualifying Offenses These crimes are only disqualifying if they are considered felonies in the appropriate jurisdiction, civilian or military. 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 last seven years or was release from prison within the last five years for any of the following crimes: · · · · · · · · · · · · Assault with intent to murder Kidnapping or hostage taking Rape or aggravated sexual abuse Unlawful possession, use, sale, manufacture, purchase, distribution, receipt, transfer, shipping, transporting, delivery, import, export, or dealing in a firearm or other weapon Extortion Dishonesty, fraud, or misrepresentation, including identity fraud Bribery Smuggling Immigration violations Violations of RICO (Racketeer influenced and Corrupt Organizations) Act or a comparable state law of an Interim Disqualifying crime Robbery Distributions of, possession with intent to distribute, or importation of a controlled substance (State laws vary on the quantity of marijuana required for the offense to be considered a felony. Typically, however, to be convicted to be convicted of felony marijuana possession, a person must possess a quantity of marijuana greater than an amount considered for "personal use".) Arson Conspiracy or attempt to commit any of these crimes. · · Part B. Permanently Disqualifying Criminal Offenses A driver will be permanently disqualified from holding a hazmat endorsement on a CDL if he or she was ever convicted or found not guilty by reason of insanity of any of the following crimes: · · · · · · Espionage Sedition Treason Any crime listed in 18 U.S.C. Chapter 113B Terrorism or a comparable state law A crime involving a severe transportation security incident (i.e., security incident involving a significant loss of life, environmental damage, transportation system disruption, or economic disruption in a particular area) Improper transportation of a hazardous material under 49 U.S.C. 5124 or a comparable s
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