Permit Renewal

Do You Have Any Restrictions Listed on Your Drivers License? (E.g. Corrective Lenses)
IDENTIFY SPECIFIC TYPE OF EQUIPMENT AND LOCATION OF OPERATION
(Check all that apply):
Aerial Lifts
Cranes
Powered Industrial Vehicles
Tractor
Mobile Equipment
I certify that the operator listed above has operated the indicated equipment in a safe manner and does not require refresher training at this time. The operator has not been involved in an equipment accidents or near miss incidents. The equipment listed has not been modified and the equipment location has not been altered. The operator continues to safely and effectively operate the equipment, including (but not limited to) the following functions:
  • Shows familiarity with the controls
  • Obeys all signs
  • Yields to pedestrians
  • Maneuvers with load properly
  • Follows proper procedures at both start and finish
Evaluator/Supervisor Signature(Required)
Clear Signature
MM slash DD slash YYYY
Michigan Block M

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