CSC Form 665 – Fill Out and Use This PDF

Updated: Nov 11, 2026

The CSC Form, approved by the United States Civil Service Commission and identified by Budget Bureau No. 50-R0279, is a detailed document aimed at evaluating the ability to drive safely. It is designed for individuals applying for positions that require the operation of motor vehicles and mobile equipment, covering aspects ranging from general information and traffic violations to accident records and safety awards. Potential applicants are encouraged to complete both sides of the form meticulously, with assistance if necessary, to provide a comprehensive overview of their driving history and capabilities.

To commence your application process, please ensure you have accurately filled out every section of the CSC Form. Click the button below to proceed.

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How to Fill Out CSC Form 665

CSC Form 665 at a glance

What it is: United States Civil Service Commission CSC Form 665 is the Ability to Drive Safely Experience Statement Sheet for Motor Vehicle and Mobil Equipment Operators.

Who signs: Sign under Signature of applicant.

A filled-in CSC Form 665 example: a driver applicant lists one traffic violation

CSC Form 665 example filled out, example: a driver applicant lists one traffic violation — Dale Sample, a delivery driver, fills out CSC Form 665. He applies for a truck driver position and reports one speeding ticket from March 2025. The picture shows page 1 filled in, and every value in it is made up. Dale marks No for License revoked or suspended?, Yes for Fined or forfeited collateral? and No for Sentenced?; the picture does not show these marks. Dale lists one violation, so the other two rows of B. Traffic Violations stay empty. Dale's present license has no restrictions, so Restrictions listed in present license stays empty. Dale obtained no license in another state, so Other States where you obtained license during the past 5 years stays empty. Dale had no accident, so D. Accident Record stays empty. Dale has no safety award, so E. Safety Awards stays empty. Dale signs the form later, so Signature of applicant stays empty.

How to fill out CSC Form 665, box by box

A. General Information and B. Traffic Violations

Under A. General Information, enter the Title of position applied for, the Date, your Name (First, middle, last) and your Birth date (Month, day, year).

Under 5, enter your Address (Number and street, or RD number, city, state, and ZIP Code). Under B. Traffic Violations, supply the information requested for each time you were given a ticket or arrested for breaking a driving law during the past 5 years. Do not include any record where you were found not guilty. Also do not include parking tickets.

For each violation, enter the Type of violation, Mo/Yr., While on job?, City, County, State, and Details of action taken (Length of suspension, amount of fine, etc.).

Mark Yes or No for License revoked or suspended?, Fined or forfeited collateral? and Sentenced?

C. Driver's License Information

Under C. Driver's License Information, enter the Driver's permit or license number, the State in which it was issued, the Date it expires, the Restrictions listed in present license and the Other States where you obtained license during the past 5 years.

D. Accident Record

Under D. Accident Record, complete the information requested for each accident you have had during the past 5 years, whether your fault or not.

For each accident, enter the Type of accident (Head-on collision, hit a tree, etc.), Mo./Yr., While on job? and City, County, State.

Mark Yes or No for While on job?, and enter the Amount of damage to your car and the Amount of damage to the other party's car.

Mark Yes or No for Did you or your insurance company make payment to the other party?; if Yes, give amount.

Mark Yes or No for Was anyone killed? and Were you judged at fault?

Describe charges placed against you, if any, mark Yes or No for License revoked or suspended, Fined or forfeited collateral? and Sentenced?, and enter the Details of action taken (sentenced length of suspension, amount of fine, etc.).

E. Safety Awards

Under E. Safety Awards, mark Yes or No for Have you ever received a safety award? and for Have you ever received a citation for safe driving or for being a safe worker?; if yes, give details, including date received.

Signature of applicant

You certify that all of the statements made in this application are true, complete, and correct to the best of your knowledge and belief and are made in good faith.

Enter the Date.

More rules for CSC Form 665

Fill in both sides of this form. You may have someone help you complete it if you wish.

If you had more than three traffic violations or two accidents within the last 5 years, provide the information requested in B and D for each on additional sheets.

Sources

[1] CSC Form 665 (no printed edition), United States Civil Service Commission (the Official source link on this page).

CSC Form 665 PDF Details

CSC Form 665 is a two-page Experience Statement Sheet issued by the United States Civil Service Commission. Federal agencies require this document from candidates for positions that involve operating motor vehicles or mobile equipment. It assesses whether a candidate has a safe, responsible driving history before they are placed in roles where they will operate government vehicles or heavy equipment.

The document is organized into five main sections. The first section collects personal information including the candidate's name, address, and the position applied for. The second section captures all traffic violations from the past five years, excluding cases where the candidate was found not guilty and parking tickets. For each violation, candidates must provide the type of offense, city and state, dates, and details of any fines, license suspension, or sentencing. The third section records current driver's license details including the issuing state, expiration date, and any other states where the candidate has held a license. The fourth section covers accident history, requiring details about each incident including type of collision, location, damage amounts, whether anyone was killed, charges placed against the candidate, and fault determination. The fifth section asks about safety awards or citations received for safe driving, with space to provide dates and descriptions of any recognition.

Candidates should review their driving history and gather documentation before completing the form to ensure accuracy. The document must be filled out on both sides. Providing false or incomplete information on a federal civil service form may result in disqualification from the position.

Question	Answer
Form Name	CSC Form 665
Also Known As	Experience Statement Sheet
Issuing Authority	U.S. Civil Service Commission
Approval Number	Budget Bureau No. 50-R0279
Form Length	2 pages
Fillable?	No
Avg. time to fill out	30 sec
Other names	csc application form, csc form download, csc form apply, csc form pdf