Navfac 11240 10 Form – Fill Out and Use This PDF

APPLICATION FOR VEHICLE OPERATOR'S IDENTIFICATION CARD

NAVFAC 11240/10 (REV. 10-75) S/N 0105-LF-012-4055

NEW

RENEWAL

(See Privacy Act statement and instructions on reverse)

PART I - APPLICATION

13. SHOP NAME/NUMBER AND APPLICANT'S BADGE NUMBER					14. SUPERVISOR (Name)				15. PHONE NUMBER
16a.	TYPE OF IDENTIFICATION	16b. TYPES OF VEHICLES TO BE OPERATED
	CARD (Check)		(Check)
	REGULAR		PASSENGER CAR			BUS (GAS AND DIESEL)		TRUCK 4 x 4
	RESTRICTED		PICKUP TRUCK			TRUCK TRACTOR & SEMITRAILER		TRUCK 6 x 6
	EXPLOSIVE		TRUCKS TO 2 TONS			FIRE TRUCK		TRUCK FIRE/CRASH
	EMERGENCY VEHICLE		TRUCKS TO 5 TONS			AMBULANCE		TRUCK TANK
	AVGAS REFUELER		TRUCKS TO 10 TONS			MOTORCYCLE & SCOOTERS		OTHER (Explain below)

17.EXPLANATION

18.VALID STATE VEHICLE OPERATOR'S LICENSE(S)

19. SIGNATURE OF REQUESTING OFFICIALDate

PART II - OPERATOR'S PAST PERFORMANCE RECORD

		LICENSES ISSUED		NO. YRS.	LIST ACCIDENTS, VIOLATIONS, ARRESTS
DATE	VEHICLE TYPE/SIZE			DRIVING
		STATE	OTHER	EXP.	(If any) AND ACTION TAKEN
1	2	3	4	5	6

PART III - EXAMINATION RESULTS

	1. SCORES IN DRIVING TESTS		2. SCORES ACHIEVED			3. GOVERNMENT VEHICLES AUTHORIZED
			IN TESTS			TO OPERATE (List)
	SAT	UNSAT		SAT	UNSAT
	a. ROAD TEST		a. WRITTEN
			b. PHYSICAL
	b. EQUIPMENT INSPECTION		c. PSYCHOPHYSICAL
	REMARKS

PART IV - ACTION BY ADMINISTERING OFFICIAL

3. IDENTIFICATION CARD MARKED "VOID UNLESS ACCOMPANIED BY VALID STATE LICENSE

4. OPERATOR INSTRUCTED TO TURN IN IDENTIFICATION CARD UPON LOSS OR SUSPENSION OF STATE DRIVER'S LICENSE

INSTRUCTIONS FOR COMPLETING APPLICATION FOR VEHICLE OPERATOR'S IDENTIFICATION CARD

NAVFAC 11240/10 (REV. 10-75)

PRIVACY ACT STATEMENT

Authority to request this information is derived from Title 40 United States Code 471. Purpose of this form is to obtain information to determine whether an individual is qualified to operate a government vehicle and/or equipment. Information is used by agency transportation officials and may be used by government and civil law enforcement authorities for court action. Providing information for this form is mandatory. If the information is not provided, the individual would be denied the privilege of operating a government vehicle and/or equipment.

GENERAL

Prepare in duplicate. File original in applicant's personnel jacket and retain copy in issuing office. Use typewriter or ball-point pen.

PART I - APPLICATION

1.Self-explanatory.

2.Enter military rank/rate or civilian grade and title.

3.Enter name and location of activity. Abbreviations may be used.

4.Self-explanatory.

5.Enter day, month and year of birth.

6.Enter city/town and state of birth.

7.Self-explanatory.

8.Enter male or female.

9.Self-explanatory.

10.Enter height in feet and inches; i.e., 6'2".

11.Enter color of hair; i.e., brown, black, gray.

12.Enter color of eyes; i.e., blue, brown, hazel.

13.Enter shop name and number, plus applicant's badge number.

14.Enter the name of the applicant's supervisor.

15.Enter the telephone number of the applicant's supervisor; i.e., 74056.

16.a. Check type of identification card applied for.

b. Check types of vehicles to be operated for which operator's identification card is to be issued.

17.List other types of vehicles that applicant is required to operate not listed under 16 b.

18.Enter current valid state (name and number) vehicle operator's license(s).

19.Signature of requesting official; i.e., Commanding Officer or designated representative and date.

PART III - OPERATOR'S PAST PERFORMANCE RECORD

1.Self-explanatory.

2.Enter vehicle type/size that applicant is or has been authorized to operate.

3.Enter date of issue of previous or present state vehicle operator's license.

4.Enter date of issue of previous identification cards (if any).

5.Enter number of years of driving experience, both civilian and military, for each license entry.

6.Briefly list accidents, violations, arrests, if any, and action taken.

7.Signature of applicant and date.

PART III - EXAMINATION RESULTS

1&2. Check appropriate boxes.

3.List types of Government vehicles authorized to operate; i.e., pickup truck, truck tank.

4.Enter remarks, if any, the examiner considers necessary; i.e., restrictions, driving weaknesses, outstanding qualifications.

PART IV - ACTION BY ADMINISTERING OFFICIAL

1.Check appropriate box.

2.Enter serial number of identification card issued, date issued, and expiration date.

3.The phrase "Void unless accompanied by valid state license" may be overstamped on the card or typed on the back under "Other Records."

4.Check appropriate box.

5.Signature of administering official and date.

NAVFAC 11240/10 (REV. 10-75) (BACK)