Driver License Hazardous Meterials Endorsement Application

DRIVER LICENSE HAZARDOUS MATERIALS ENDORSEMENT SPECIAL INSTRUCTIONS

Wisconsin Department of Transportation MV3735 12/2019 Ch. 343 Wis. Stats.

Section 1. Proof of Citizenship or Permissible Immigration Status to Hold Hazardous Materials

Endorsement (HME)

An applicant must be one of the following:

• A citizen of the U.S. who has not renounced or lost his/her U.S. citizenship

• A lawful permanent resident of the U.S. as dened in section 101(a)(20) of the Immigration and

Nationality Act (8 U.S.C. 1101)

Section 2. List of Disqualifying Criminal Oenses for Hazardous Materials Endorsement

Part A. Interim Disqualifying Oenses

A driver will be disqualied from holding an HME if he or she was convicted or found not guilty by reason

of insanity within the last seven years or was released from incarceration within the last ve years for any

of the following crimes in any jurisdiction, military or civilian:

•Assault with intent to murder

•Kidnapping or hostage taking

•Rape or aggravated sexual abuse

•Unlawful possession, use, sale, manufacture, purchase, distribution, receipt, transfer, shipping,

transporting, delivery, import, export of, or dealing in a rearm or other weapon

•Extortion

•Dishonesty, fraud, or misrepresentation, including identity fraud

•Bribery

•Smuggling

•Bomb threat

•Immigration violations

•Violations of RICO (Racketeer Inuenced and Corrupt Organizations) Act 18 U.S.C. 1961, et. seq.,

or a comparable state law of Interim Disqualifying criminal oenses

•Robbery

•Distribution of, possession with intent to distribute, or importation of a controlled substance

•Arson

•Conspiracy or attempt to commit any of the crimes listed in Part A

•Fraudulent entry into a seaport as described in 18 U.S.C. 1036, or a comparable state law

Part B. Permanent Disqualifying Criminal Oenses

A driver will be permanently disqualied from holding an HME if he or she was ever convicted or found

not guilty by reason of insanity of any of the following crimes in any jurisdiction, civilian or military:

• Espionage

• Sedition

• Treason

• A federal crime of terrorism as dened in 18 U.S.C. 2332 b(g), or comparable state law

• A crime involving a transportation security incident

• Improper transportation of a hazardous material under 49 U.S.C. 5124 or a comparable state law

• Unlawful possession, use, sale, distribution, manufacture, purchase, receipt, transfer, shipping,

transporting, import, export, storage of, or dealing in an explosive or explosive device

• Murder

• Conspiracy or attempt to commit any of the crimes listed in Part B

• Violations of RICO (Racketeer Inuenced and Corrupt Organizations) Act 18 U.S.C. 1961, et. seq.,

or a comparable state law of Permanent Disqualifying criminal oenses

Go to Application

PRIVACY ACT STATEMENT

Authority: 6 U.S.C. § 1140, 46 U.S.C. § 70105; 49 U.S.C. §§ 106, 114, 5103a, 40103(b)(3), 40113, 44903,

44935-44936, 44939, and 46105; the Implementing Recommendations of the 9/11 Commission Act of 2007, §

1520 (121 Stat. 444, Public Law 110-52, August 3, 2007); and Executive Order 9397, as amended.

Purpose: The Department of Homeland Security (DHS) will use the biographic information to conduct a

security threat assessment. Your ngerprints and associated information will be provided to the Federal

Bureau of Investigation (FBI) for the purpose of comparing your ngerprints to other ngerprints in the FBI’s

Next Generation Identication (NGI) system or its successor systems including civil, criminal, and latent

ngerprint repositories. The FBI may retain your ngerprints and associated information in NGI after the

completion of this application and, while retained, your ngerprints may continue to be compared against other

ngerprints submitted to or retained by NGI. DHS will also transmit your ngerprints for enrollment into US-

VISIT Automated Biometrics Identication System (IDENT). If you provide your Social Security Number (SSN),

DHS may provide your name and SSN to the Social Security Administration (SSA) to compare that information

against SSA records to ensure the validity of the information.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. 522a(b) of the Privacy

Act, all or a portion of the records or information contained in this system may be disclosed outside DHS

as a routine use pursuant to 5 U.S.C. 522a(b)(3) including with third parties during the course of a security

threat assessment, employment investigation, or adjudication of a waiver or appeal request to the extent

necessary to obtain information pertinent to the assessment, investigation, or adjudication of your application

or in accordance with the routine uses identied in the TSA system of records notice (SORN) DHS/TSA

002, Transportation Security Threat Assessment System. For as long as your ngerprints and associated

information are retained in NGI, your information may be disclosed pursuant to your consent or without your

consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any

time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine

Uses.

Disclosure: Furnishing this information (including your SSN) is voluntary; however, if you do not provide your

SSN or any other information requested, DHS may be unable to complete your application for a security threat

assessment.

BACKGROUND CHECK PROCESS

A background check, including the collection of ngerprints, must be completed before original issuance of an

HME. A background check and ngerprinting are also required upon renewal and every 4 years thereafter,

even though a commercial driver license may be valid for eight years. An HME knowledge test, proof of a

valid medical certicate and proof of citizenship or immigration status are also required at the same intervals.

Customers must complete all of the licensing requirements for a commercial driver license and HME with

the DMV prior to making an appointment to have their ngerprints collected. Applicants should complete the

ngerprint collection within 30 days of applying for the HME endorsement. Collections completed after 30 days

may be subject to additional TSA fees.

The Wisconsin Department of Transportation (WisDOT) has entered into a contract with Fieldprint for the

purpose of collecting ngerprints for HME haulers as required under 49 CFR Part 1572 (the USA Patriot Act).

Fieldprint is a private company authorized by WisDOT, WisDOJ and the FBI to collect and submit ngerprints

of commercial drivers applying for an HME.

You will need to provide the Fieldprint code FPWIDMVHazmat to schedule your ngerprint appointment.

Fieldprint requires that you make an appointment at www.FieldprintWisconsin.com for ngerprinting

services. Fieldprint will collect the background check and ngerprinting service fees. You can make payment

by credit or debit card.

You must bring two forms of identication to your ngerprint appointment, a picture ID and a secondary ID.

When you schedule your ngerprint appointment online, the appointment conrmation you print will list the

acceptable identication documents.

DRIVER LICENSE HAZARDOUS MATERIALS ENDORSEMENT APPLICATION

Wisconsin Department of Transportation

MV3735 12/2019 Ch. 343 Wis. Stats.

* SOCIAL SECURITY NUMBER (SSN) Any applicant MUST provide his/her SSN, which may be used for purposes

authorized by law. It may also be used to link your driver license and vehicle registration records. It must correspond

with the number issued by the Social Security Administration, which is

required by s.343.14(2)(bm) Wis. Stats.

Print all requested information in black ink.

Wisconsin Driver License Number Social Security Number* Product Number

Customer Legal Name – Last First Middle Sux

Birth Date – Month Day Year – 4 digits Gender

Male Female

Race Eye Color Hair Color Weight Height

Current Residential Address – Street Apt # City State ZIP Code County of Residence

Previous Residential Address – Street Apt # City State ZIP Code County of Residence

Place of Birth – Country State City

Proof Provided of Legal U.S. Residence (documents must be provided to Wisconsin DMV personnel)

See front page – Special Instructions, Section 1 of this form

U.S. Passport

Certicate of Birth Abroad issued by the U.S. Department of State

Certicate of U.S. Citizenship (form N-560 or N-561)

Certied Birth Certicate issued in the U.S.

Certicate of Naturalization (form N-550 or N-570)

Permanent Resident Card I-551

Temporary I-551 stamp on form I-94

Temporary I-551 stamp in Foreign Passport

Re-entry Permit I-327

Country of Citizenship Alien Registration Number Naturalization Date

Military Service

Branch Discharge Date Dishonorable Discharge

Yes No

Clear Form

Select Month

Answer all questions. See front page – Special Instructions, Section 2 of this form for list of crimes.

YES NO

1. Have you been convicted or found not guilty by reason of insanity of any of the disqualifying

crimes listed in Section 2, Part A within the last 7 years in any jurisdiction, military or civilian?

2. Have you been released from incarceration for committing any of the disqualifying crimes listed

in Section 2, Part A within the last 5 years in any jurisdiction, military or civilian?

3. Are you wanted or under indictment for any disqualifying crime listed in Section 2, Part A and

Part B, in any jurisdiction, military or civilian?

4. Have you been convicted or found not guilty by reason of insanity of any of the disqualifying

crimes listed in Section 2, Part B, in any jurisdiction, military or civilian?

5. Have you been adjudicated as lacking mental capacity or committed involuntarily to a

mental institution?

Current Employer – Name (Area Code) Telephone Number

Current Employer

Address – Street Apt # City State ZIP Code

Country

Second Employer – Name (Area Code) Telephone Number

Second Employer

Address – Street Apt # City State ZIP Code

Country

I, the undersigned, have been informed that Federal regulations under 49 CFR 1572.11 impose a continuing obligation to

disclose to the Wisconsin Department of Transportation within 24 hours if I am convicted of, wanted, under indictment, or

found not guilty by reason of insanity of any disqualifying crime, or adjudicated as lacking mental capacity, or committed

involuntarily to a mental institution, renounce or lose my U.S. citizenship, or violate my immigration status and/or am

ordered removed from the U.S. while I have a hazardous materials endorsement for a commercial driver license.

The information I have provided on this application is true, complete, and correct to the best of my knowledge and belief

and is provided in good faith.

I understand that a knowing and willful false statement, or an omission of a material fact, on this application can be

punished by ne, or imprisonment, or both (see section 1001 of Title 18 United States Code), and may be grounds for

denial of a hazardous materials endorsement.

(Applicant Signature) (Date Signed – m/d/yyyy)

WisDOT OFFICE USE ONLY

(DMV Processor Signature) (Processor ID) (Date Processed – m/d/yyyy)