SECTION I - OFFICIAL QUALIFICATIONS - Fort …

1 SECTION I - OFFICIAL QUALIFICATIONSS pecial equipment , special operations or conditionsCity, rural, long haul, OF EQUIPMENTSIZEQUALIFIED ATNAME OF EXAMINERDATE QUALIFIEDSPECIAL QUALIFICATION1 equipment operator 'S qualification RECORD (EXCEPT AIRCRAFT) (AR 600-55 and AR 385-55) DATECREDITSDEBITSTYPE OR NATUREACTION TAKENSECTION III - PERFORMANCE RECORD (List chronologically as "credits" - awards, training, retraining, testing, retesting, roadeos, permit renewal, relicensing, etc; and as "debits" - accidents, arrests, violations, warnings, revocations, suspensions, etc.) PERMIT (Initial) SECTION II - BACKGROUND AND EXPERIENCETYPE OF EQUIPMENTSIZETYPE OF DRIVINGOR OPERATIONADDITIONALDRIVER'S LICENSES (State or agency) NUMBER OF OTHERDRIVER'S LICENSESSATISFACTORY EXPERIENCEVERIFIED BYNAME (Last, first, initial) AND SERVICE NUMBERNUMBERDATE ISSUEDTYPELIMITATIONS (Physical or operational) SEXDATE OF BIRTHCOLOR HAIRCOLOR EYESHEIGHTWEIGHTPOSITION TITLE (If civilian) 212DA FORM 348, OCT 64 REPLACES DA FORM 348, 1 AUG 60, WHICH WILL BE USED,AND DD FORM 1360 WHICH IS OBSOLETE FOR ARMY USE.

2 (Extract from personnel file tomaintain at operating level.)USAPA IV - EXAMINATION FINDINGSSTARTOIL LEVEL STICKTACHOMETERTEMPERATUREGAGEOIL PRESSUREGAGEVOLTOMETERAIR PRESSURE GAGEFUEL TIRESHORNHANDBRAKESCLEANHEADLIGHTSFOOTBR AKESOILLEVELBAT-TERYWATERLEVELLOCAL LAWSOPERATINGPROCEDURESACCIDENTREPORTING MY DRIVING WEAKNESSES HAVE BEENMADE KNOWN TO ME AND I HAVE BEENSHOWN HOW TO OVERCOME OR ADJUST THEM. ROAD TEST SCORENUMBER OF TALLY MARKS ON CHECK LIST PRT 2678 (Subtract) 100 ROAD TEST - SCORED PHASE (DA PRT 2678) 7. ADDITIONAL REQUIREMENTS FORLICENSE16. PRACTICE RUN (mile)2(Two feet from target)5. DEPTH PERCEPTION(Location and use)3. EMERGENCY EQUIPMENTROAD TEST - PREREQUISITEDRIVING PERFORMANCE TEST (Check " " if successful, "x" if failed and corrective training is needed)DA FORM 6122DA FORM 6123DA FORM 6124 BATTERY I - (Administeredas a part of reception pro-cessing, at reception stations) (To be administered to all applicants for Driver Permit SF 46) (To transfer raw score to standard scoresee DA Pamphlet 611-119)BATTERY II -NOYESSUCCESSFUL COMPLETIONSTANDARD SCORE FOR BATTERY II (Divide Total Standard Score by 3) ENTER SCORE FROMITEM 24 OF INDIVID-UAL'S DA FORM 20 TOTAL STANDARD SCORE- IF QUALIF'D- IF EVALUATION MEASURESSIGNATURE OFEXAMINER1.

3 INSTRUMENTS(Location, correct read-ing, action for abnormalreading)2. BEFORE OPERATION CHECK4. CONTROLS - "DRY RUN"AMMETERII1. VISUAL ACUITY2. FIELD OF VISION3. HEARING4. REACTION TIME5. DEPTH PERCEPTION6. COLOR PERCEPTIONooRAW SCORESTANDARD SCORECOMMENTS AND RECOMMENDATIONS ONSUBSTANDARD ITEMS/100 SEC/100 SEC/20/20 HIGHWAY WARNING KITTHIRD TRYSECOND TRYFIRST TRYFRONT AXLECLUTCHBRAKEGEARSOTHER (Describe)FIRE OUTSHIFT3 STOPSTURNSBACKINGREVERSE, DA FORM 348, OCT 64 USAPA SCORE LEFT EYE RIGHT EYE RIGHT EAR LEFT EAREXAMINATION ADMINISTERED BY (Last name - first name - middle initial) LEFT EYE20/ RIGHT EYE20/ SIGNATURE OF MEDICAL AUTHORITY OTHER (Describe) COMMENTS AND RECOMMENDATIONS OF ROAD TEST EXAMINERSIGNATURE OF ROAD TEST EXAMINERDATESIGNATURE OF APPLICANT