Fill and Sign the Statutory Visa Form

Print Form AUTHORIZATION FOR OPERATION OF MOTOR VEHICLES AND/OR EQUIPMENT (Manager or supervisor completes this form). This authorization must be supported by additional training documentation as appropriate for each type of motor vehicle or equipment the operator is authorized to operate. Operator Name: Station Name: Type of Authorization: New Updated *Suspended/Date: Service Employee Volunteer Partner Yes No (Attach a copy of license) Regular (or) Commercial Driver's License (CDL) Yes No * Yes No * * Explanation of suspension: Operator must be either: Does operator carry a valid State driver's license? Type of State driver's license required: Class of State's driver's license (List CDL endorsements if applicable): Date(s) defensive driver training completed: Does operator carry a valid agency identification card or document? * Explain: Is operator physically and medically qualified as required? * Explain: Types of motor vehicles and motor equipment authorized to operate (check those that apply). Attach safety training documentation. Unless required by a supervisor, items marked with a (*) do not require safety training other than the possession of a valid State license for that vehicle class. STATE LICENCE REQUIRED* HEAVY EQUIPMENT SAFETY TRAINING REQUIRED Sedans Agricultural Tractors Station Wagons Crawler Loaders Vans: less than 15 passengers Crawler Dozers Scraper Pans Type ORUV: Trucks: under 8500 GVW Backhoe/Loaders Draglines Type ORUV: Trucks: 8500-26000 GVW Motor Graders Cranes Type ORUV: Trucks: > 26001 GVW (CDL) Skid Steers Truck/Trailer: >26001 GVW (CDL) Excavators Other: Type: Buses/Trams/Shuttles (CDL) 4 Wheel Drive Loaders Other: Type: Motorcycles Specialty Tracked Equipment (STE) Other: List STE: Forklift (PIT) ORUV/OTHER EQUIPMENT TRAINING Forklift Class: Crane Ton Rating: Off-Road Utility Vehicles (ORUV) Type ORUV: Riding Lawn Mower less than 35 HP Other: Type: Additional Comments: Supervisor's Authorization: I conclude that this employee/volunteer/partner is fully trained and otherwise qualified to operate the motor vehicles or motor equipment checked above in a safe and effective manner. I hereby authorize such operations subject to the following conditions: Conditions: Supervisor Name (print): Supervisor Signature: Date: * Employee/Volunteer/Partner Signature: Date: * By my signature, I confirm there are no active or pending suspensions or revocations against my personal State driver's license. FWS Form 3-2267 REV 04/11