Fatigue Management Certificate Request Form

When you have completed the Fatigue Management Program, you will have completed 1 of the 4 Home Run for Safety Award programs.
After a company official completes the Management program and all of their drivers have completed the 4 core Home Run programs, the
company is eligible to receive a Home Run for Safety Award.

Congratulations on completing the Fatigue Management Program! You will find that the safety training you have received provides valuable
knowledge and techniques you may use to improve your safety record during your driving career. If you have questions please contact us:
info@truckingsafety.org

Fill out this form to obtain an official certificate for completing the Michigan Center for Truck Safety's Fatigue Management program.

IF YOU HAVE NOT COMPLETED THE PROGRAM YET, DO THAT FIRST AND THEN COME BACK HERE AND REQUEST YOUR CERTIFICATE!!!


Date of Program completion:
Name as you want it on your certificate
Email:
Phone:
Driver License Number:
Licensing State:
Year of Birth:
License Type:
CDL Category:
List Endorsements (T,N, H, P,S):
Position:
Years as a DOT regulated driver:
Are you trying for the Home Run Award?
How did you find the Center's programs?
Scope of Company operation:
Company Name (or Driving School) (if none mark n/a):
Company Address (if none mark n/a):
Certificates for Baker College Students
who do not indicate their campus location
will be mailed to the Flint Campus.
Your mailing address (street address, city,
state and zip):