Form 412 Application for School Bus Endorsement Alaska

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STATE OF ALASKA DIVISION OF MOTOR VEHICLES APPLICATION FOR SCHOOL BUS ENDORSEMENT This application is for: Original 5 Year Renewal APPLICANT’S FULL LEGAL NAME (PLEASE PRINT) DATE OF BIRTH (Must be at least 21) MAILING ADDRESS CITY STATE ZIP ALASKA DRIVER LICENSE NUMBER CONTACT PHONE NUMBER EMAIL ADDRESS SCHOOL DISTRICT OR CONTRACTOR FOR WHOM DRIVING EMPLOYER PHONE NUMBER Have you ever been convicted for an offense listed on the backside of this application? Yes No If you answered “Yes”, please list the conviction type, state where the conviction occurred, and the conviction date . Note: Any offense listed where the disqualification period has not elapsed or is a lifetime disqualification, your application will be rejected. Conviction Type State Where Conviction Occurred Conviction Date I certify that the above is true and accurate to the best of my knowledge. I understand it is my responsibility t o provide copies of this application to the District School Superintendent and my employer. Applicant’s Signature Date The following items are required for an original School Bus Endorsement: Application for a Driver’s License Application for School Bus Endorsement (form 412)** Department of Transportation Medical Certificate issued under 49 C.F.R. 391.41 Skills (Road) test in a representative School Bus (Required in all areas of the state.) Background Check Authorization Form CETA-0 8 ** A completed fingerprint card for the background check ** Pre-printed check or money order made out to the State of Alaska for background check fee for $48.25. ** Certifica te of Completion of a Department of Education approved school bus driver training course (issued within the last 2 years) ** The following items are required for the renewal of a School Bus Endorsement : Application for a Driver’s License Application for a School Bus Endorsement (form 412) ** Department of Transportation Medical Certificate issued under 49 C.F.R. 391.41 Background Check Authorization Form CETA-0 8 ** A completed fingerprint card for the background check ** Pre-p rinted check or money order made out to the State of Alaska for background check fee for $48.25. ** Certificate of Completion of a Department of Education approved school bus driver training course (only required if y ou have not held a valid Alaska license and School Bus endorsement for the previous two years) ** ** Items that are forwarded as part of the School Bus Packet, all other items are scanned as part of the issuance. Form 412 (Rev. 1 0 /202 2 ) ALASKA.GOV/DMV Background checks are conducted by the Alaska Department of Public Safety and a national criminal history background check by the Federal Bureau of Investigation (FBI). The resulting report will be reviewed by the Division of Motor Vehicles for the disqua lifying convictions listed below pursuant to Alaska Statute 28.15.046 and is conducted in accordance with AS 12.62.160, AS 12.62.400 and Title 28, C.F.R., § 16.34. To obtain a copy of the criminal justice report, to update or to correct information on t hat report in accordance with AS 12.62.170, contact the Department of Public Safety at http://dps.alaska.gov/statewide/background/ . Information on how to obtain a copy, update or correct informat ion on the FBI identification record is available at http://www.fbi.gov/ . Lifetime Disqualifications after conviction for: • Murder, Manslaughter, Criminally Negligent Homicide, including that of an unborn child, Assault and Reckless Endangerment in the 1 st – 3 rd degrees (AS 11.41.100 – 220) • Stalking in the 1 st – 2 nd degrees (AS 11.41.260 – 270) • Assault on an Unborn Child in the 1 st – 2 nd degrees (AS 11.41.280 – 289) • Kidnapp ing or Custodial Interference in the 1 st degree ( AS 11.41.300 – 320) • Human Trafficking in the 1 st or 2 nd degrees (AS 11.41.360 -370) • Sexual Assault in the 1 st – 4 th degrees or Sexual Assault of a Minor in the 1 st – 4 th degrees (AS 11.41.410 – 445) • Incest, On -line Enticement of a Minor, Unlawful Exploitation of a Minor, Indecent Exposure in the 1 st – 2 nd degrees (AS 11.41.450- 470) • Robbery in the 1 st – 2 nd degree s, Extortion or Coercion (AS 11.41.500 – 530) • Felony - Endangering of a Child in the 1 st degree (AS 11.51.100) • Felony - Indecent Viewing or Photography, Distribution or Possession of Child Pornography, Distribution of Indecent Material to Minors (AS 11.61.123-128) • Felony - Prostitution or Sex Trafficking in the 1 st – 3 rd degrees (AS 11.66.100(e ), AS 11.66.110 – 130) • Felony - Involving Distr ibution of a Controlled Substances or Imitation Controlled Substances (AS 11.71, AS 11.73) • Felony - Driving Under the Influence or Felony Refusal to Submit to a Chemical Test (AS 28.35.030(n), AS 28.35.032 (p)) * Unless allowed by regulation Disqualified for 10 years after date of conviction for: • Operation of a Commercial Motor Vehicle While Under the Influence (AS 28.33.140(a)(1)) • Refusal to Submit to a Chemical Test under AS 28.35.032, while driving a commercial vehicle ( AS 28.33.140(a)(2)) • Leaving the Scene of an A ccident under AS 28.35.060 or providing false information on an accident report in violation of AS 28.35.110 (AS 28.33.140(a)(4)) • Felony conviction under state or federal law that was facilitated by use of a motor vehicle (AS 28.33.140(a)(5)) • Negligent Operation of a commercial vehicle that caused a fatality or operation of a commercial in violation of a felony criminal law (AS 28.33.140(10)) • Convicted of two or more misdemeanor Driving Under the Influence (AS 28.35.030) or Refusal to Submit to a Chemical Test (AS 28.35.032) or a combination of those offenses * Unless allowed by regulation Disqualified for 2 years after the conviction for: • Assault in the 4 th d egree (AS 11.41.230)* • Reckless Endangerment (AS 11.41.250)* • Contributing to the Delinquency of a Minor (AS 11.51.30)* • Misdemeanor - Prostitution (AS 11.66.100(a)(2))* • Misdemeanor - Endangering the Welfare of a Child in the 1st degree (AS 11.51.100) • Misdemeanor – First Conviction Driving Under the Influence or Refusal to Submit to a Chemical Test (AS 28.35.030 or AS 28.35.032) * Unless allowed by regulation