| UW MADISON - NOTARIZED STATEMENT OF DRIVING RECORD |
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| This is to inform
you that I presently hold a valid license from the state of: |
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| I have had my Wisconsin
license for less than 3 current years. I previously held a valid driver's license
from the State of: |
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| Please include
a photo copy of your out-of-state license. |
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| The following
is a true statement of my driving record for the past three years:
1) I have been ticketed for the following moving violations in the past 3 years. If none, please enter "None". For speeding citations, list how many miles over the speed limit you were cited. |
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| Date | Citation | |
2) I have been involved in the following accidents in the past three years. If none, please enter "None". |
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| Date | Description of Accident | Ticket? Yes or No? |
| The
Following Must be Completed in the Presence of a Notary |
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| Signature of Driver:
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Date: |
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Subscribed and sworn to , before me this ____ day of ____________, 20 ____ |
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My commision expires: |
County of: | |
Signature of notary: |
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