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ATTACHMENT C: CDL EXAMINER REQUEST FORM <br /> <br />Department of Licensing Page 26 of 36 Contract No. K9319 <br />Submit <br />Commercial Driver License Third Party Examiner Request <br />As a result of your commercial driver training provided by your school district or a transit organization, you can <br />send this form to CDL Centralized Scheduling for authorization to skills test with a Third Party Examiner. The <br />CDL skills testing fees will be collected by your Third Party Examiner, when applicable. <br /> <br />Before your skills test can be scheduled you must submit this form and the completed Employer training <br />certificate. Once we reply your forms have been approved, the skills test can be scheduled. <br /> <br />This form is intended for use with a contracted ESD, School District, or Transit entity. All requests from <br />non-contracted entities, must follow centralized scheduling procedures. <br /> <br />This form must be filled out, signed, and submitted electronically. <br />Use the SUBMIT button on this form when completed. We will not accept handwritten forms. <br /> <br />Driver information <br />Driver name (Last, First, Middle initial) Washington driver license number <br />10-digit phone number Email <br />Training organization (check one) <br />School district <br />School district and contractor (if applicable) <br />Name of authorized representative trainer <br />Fee submitted to (provide name of agency, company, individual, etc.) Skills test fee amount Receipt provided? <br />Yes No <br />Transit organization <br />Transit department <br />Name of authorized representative trainer <br />10-digit organization phone number Organization email <br />I understand that the Department of Licensing has the right to refuse this request in the interest of public safety. <br /> <br />Authorized representative – When completed, sign below and submit this form using the Submit button. <br />By typing your name on the signature line, you declare under penalty of perjury under the law of Washington <br />that the information you have provided is true and correct. <br />X <br />Date and place signed Authorized representative typed signature <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />CDL-522-018 (R/4/25)EA <br /> <br />Docusign Envelope ID: 4798BD77-1E90-44A1-9098-432C0EDF7393