Form 4 Form 4 Probation Period 1 Benchmark Certification

O MB Number: TBD

Expiration date: TBD

Apprentice Driver Safety Benchmark Certification Form: 120-hour Certification

Carrier name (please print): _________________________

Apprentice driver’s name (please print): _________________________

Benchmark	Representative’s Initials	Date
Interstate, city traffic, rural 2-lane, and evening driving
Safety awareness
Speed and space management
Lane control
Mirror scanning
Right and left turns
Logging and complying with rules relating to hours of service

Carrier representative’s name (please print): ____________________

Carrier representative’s signature: _____________________________ Date: ____________