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Permit Renewal
Permit Renewal
Operator's Name
*
UM ID#
*
Operator's Uniqname
*
Job Title
*
Department
*
Do You Have Any Restrictions Listed on Your Drivers License? (E.g. Corrective Lenses)
*
Yes
No
Please List Any Restrictions on Your Driver's License
*
IDENTIFY SPECIFIC TYPE OF EQUIPMENT AND LOCATION OF OPERATION
(Check all that apply):
Aerial Lifts
Boom Supported Elevating
Manual Propelling Elevating
Self Propelled Elevating
Vehicle Mounted
Cranes
Gantry
Overhead
Powered Industrial Vehicles
Fork Lift
Utility Vehicle (Kubota/Toolcat)
Powered Pallet Jacks (Walkie)
Tractor
Tractor
Mobile Equipment
Backhoe
Bulldozer
Front End Loader
Skid Steer (Bobcat)
Telehandler
Other Equipment Not Listed
Location of Operation (bldg./dock area, shop#)
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
Supervisor
*
Dept Contact Name
*
Dept Contact Uniqname
*
Evaluator/Supervisor Name (Print)
*
Evaluator/Supervisor Signature
*
signature
keyboard
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Today's Date
If you are human, leave this field blank.
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