| Question | Answer |
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| Form Name | Kansas Escort Certification Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | escort kansas have online, escort kansas have, kansas central escort, escort kansas |
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ESCORT |
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CENTRAL PERMITS |
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CERTIFICATION |
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APPLICATION |
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New Certification # |
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Past Certification # |
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Expiration Date |
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(Assigned by Central Permits) |
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(If recertifying) |
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(Assigned by Central Permits) |
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MAILING ADDRESS |
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CONTACTS |
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CUSTOMER INFORMATION |
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Central Permits |
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Phone |
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Company Name |
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Docking State Office Building |
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Fax |
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Company Address |
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915 SW Harrison |
Room 150 |
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City |
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State |
Zip |
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Topeka, Kansas |
66612 |
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mc@kdor.state.ks.us |
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Drivers Name: |
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KANSAS CERTIFICATIONS |
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ALTERNATE CERTIFICATION |
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• Defensive Driving course or Valid CDL |
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• Without a CDL or have previously taken a Defensive driving course, state |
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certifications will be accepted for one year only. |
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• Must provide evidence of taking the driving course or copy of the CDL |
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• Recertification: Must pass a National Safety Approved Defensive Driving |
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upon application |
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Course or obtain a valid CDL |
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• Documentation shall be provided to Central Permits |
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Length of Certification : |
3 Years |
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Length of Certification: 1 Year |
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I ___________________________________, I certify that I am employed by the above named company or meet all the requirements and have obtained all the necessary
credentials in order to operate as a
I further certify, I possess a current drivers license or CDL
I further certify, I understand and agree to comply with the terms and conditions set forth in Central Permits Escort Certification program and any other restrictions provided by Central Permits or any local enforcement official. Evidence provided to the contrary will result in the immediate cancellation of the Kansas Certification.
I further certify, I have in effect all appropriate motor vehicle liability insurance coverage as required by federal state and local law for the type or certification sought I further certify, such insurance must be in force on of the date when the certification is authorized and will remain in effect for the duration of the certification
I further certify, I understand and agree to provide evidence of having obtained a Commercial Drivers License (CDL) or completing a National Safety Council approved Defensive Driving course before becoming recertified.
I further certify, I agree to discuss all bridge memo instructions and permit restrictions with the driver of the transporting vehicle before escorting a superload in Kansas.
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SIGNATURES |
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Print Name: |
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Signature of Escort Driver: |
Date: |
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Print Name: |
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Signature of Central Permits |
Date: |
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Official : |
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\\Dt00mh82\internet\www.ksdot.org\bureaus\burTrafficEng\KTC\doc\EscortCertificationApplication.doc |
Revised: 10/28/2010 |
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