Driver of the Month form

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WISCONSIN DRIVER-OF-THE MONTH/YEAR CONTEST
Sponsored by: WISCONSIN COUNCIL OF SAFETY SUPERVISORS

NOMINATION INFORMATION AND FORM

Selections are made quarterly. Deadline for all nominations is November 30, 2006

RULES FOR "DRIVER OF THE MONTH CONTEST":

A driver should be nominated for a record of safe and courteous driving. (Please share any community activities, truck driving championship competition and heroic or exceptional acts).

Company must be a member of the Wisconsin Motor Carriers Assn.

Drivers must be domiciled or reside in Wisconsin.

All drivers must be accident-free for the past year.

Current MVR copy must be submitted.

Please fill in the boxes below, print and fax or mail this form to the address below. The fax number is
(608) 833-2875. Thank you for your participation via our web site.

Driver's Name
Driver's License No
State
Home Address
City
State
Zip
Birth Date
Marital Status
# of Children
Spouse's Name
Company
Address
City
State
Zip
Driver's home terminal
Supervisor
Type of equipment/routes (Areas/parts of US where driver is experienced)
# of years as driver
Currently city or road driver
# of miles as city driver
# of miles as road driver
Career # of miles
# of times the driver has been inspected on the road by a State of Federal inspector in the past 3 years
Give details of any out of service due to such inspections
Nominated by
Title
Phone
Address
City
State
Zip

I. Driving Record with Sponsoring Employer

Date employed
# of miles driven for this company
# of preventable crashes
# of non-preventable crashes
Please submit details on non-preventable crashes
#miles driven since last crash
List dates and offenses for all traffic citations in the last three years

II. Driving Record with other Employers

List all other companies driven for
# of preventable crashes
# of non-preventable crashes

III. Non-Commercial Driving Record

Please list all dates and offenses for any traffic citations received in non-commercial driving.

Basis for Recommendation: The following is additional needed information for each driver.

A.	Sponsors Statement
B.	Record of Safe Driving
C.	Truck Driving Championships participation
D.	Demonstrated leadership ability (on or off the job)
E.	Community activities
F.	Heroic or exceptional acts

Supervisors signature:______________________________ Date:_____________

*This form should be printed out, signed by a supervisor, and mailed to our office at:

Wisconsin Council of Safety Supervisors
P.O. Box 44849
Madison, WI 53744-4849

*Don't forget to attach a photocopy of the current MVR.