I acknowledge that I am required to operate a motor vehicle as part of my employment with the U.S. Geological Survey. I hereby certify that I possess a valid State driver’s license for the vehicles that I am required to operate as part of my official duty. I further certify that my State driver’s license has not been suspended revoked or cancelled.
I agree to inform my Supervisor if my state driver’s license should be suspended, revoked, canceled, or I should be disqualified from motor vehicle operation at any time for 1 year after signing this certification.
I understand that any false statement on this form constitutes a violation of USC 1001 and is punishable by a fine of up to $10,000 or 5 years imprisonment or both.
Name of Employee ___________________________
Signature of Employee ___________________________
Date Signed: ___________________________