Fatigue Program 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

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


Fill out this form to obtain an official certificate for completing the Michigan Center for Truck Safety's Fatigue Management program.
Date of Program completion: *
First, MI and Last Name *
Make sure this is how you want to see iit on your certificate!
Email: *
Phone: *
Driver License Number: *
Licensing State: *
Only Michigan residents or those driving for Michigan based companies are eligible to receive a certificate for this program.
Year of Birth: *
Please put the year only.
License Type: *
CDL Category:
Endorsements
Only list endorsements that you have tested for or that are on your license (T,N, H, P,S):
Position: *
Years driving: *

List only the years you have driven as a DOT regulated driver - requiring a medical certificate! if none use the letter O not the number 0

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; If you go to a truck driver training school list the city / address!
Your mailing address *
IF you do not go to a truck driver training school, your certificate will be mailed to this address.