Initial Application for Driving School Instructor/Examiner
Name of Instructor
Louisiana Department of Public Safety and Corrections Public Safety Services Office of Motor Vehicles
Initial Application for Driving School Instructor/Examiner
Instructor's Driver's License Number
License Number Issued
Check the appropriate boxes for the license applied for
Classroom Instructor
Behind the Wheel Instructor
3rd Party Examiner
All
School Name
School License Number
School Address
Instructor Information
E-Mail Address
Physical Address
Date of Birth
Mailing Address, if different
Contact Phone Number
City, State, ZIP
City, State, ZIP
Education: School Attended
High School
College
Driver's Education Training
Answer each of the questions below:
HAVE YOU EVER BEEN ARRESTED, DETAINED, CHARGED, INDICTED OR SUMMONED TO ANSWER AND APPEAR FOR ANY CRIMINAL OFFENSE IN THIS STATE OR ANY OTHER STATE, EXCLUDING MINOR TRAFFIC CITATIONS? HAVE YOU EVER BEEN CONVICTED OF ANY FELONY OFFENSES RELATED TO THE OPERATION OF A DRIVING SCHOOL?
Yes ()
HAVE YOU EVER BEEN CONVICTED OF A CRIME INVOLVING VIOLENCE, DISHONESTY, DECEIT, INDECENCY OR AN OFFENSE INVOLVING MORAL TURPITUDE WITHIN THE LAST TEN YEARS? HAVE YOU EVER BEEN CONVICTED OF ANY CRIME ENUMERATED IN R. S. 15:587.1(C) (THE CHILD PROTECTION ACT)?
No ()
HAVE YOU EVER BEEN CONVICTED OF ANY MISDEMEANOR OR FELONY OFFENSES INVOLVING CONTROLLED
DANGEROUS SUBSTANCE(S) OR DRIVING WHILE INTOXICATED WITHIN THE LAST TEN YEARS?
If the answer to any of the above questions is yes, list all required information below. You MUST ALSO include a certified copy of
court disposition on all offenses and convictions. FAILURE TO INCLUDE ALL INFORMATION AND RECORDS WILL RESULT IN
DENIAL OF YOUR APPLICATION.
Offense/Conviction
Date of Offense/Conviction City, State
Disposition (Attach certified
copy of court disposition)
Initial Application for Driving School Instructor/Examiner
Page 2
Answer each of the questions below truthfully: ARE YOU A CITIZEN OF THE UNITED STATES OR AN ALIEN WHO IS LAWFULLY PRESENT IN THE UNITED STATES AND A RESIDENT OF THE STATE OF LOUISIANA?
ARE YOU AT LEAST 21 YEARS OF AGE?
DO YOU HAVE AT LEAST 5 YEARS DRIVING EXPERIENCE?
HAVE YOU EARNED AT LEAST A HIGH SCHOOL DIPLOMA OR GED? DO YOU CURRENTLY OWN OR HAVE YOU PREVIOUSLY OWNED A DRIVING SCHOOL WHICH HAD A LICENSE THAT WAS REVOKED OR SUSPENDED FOR VIOLATION OF RULES?
If yes, please list the name of the school
Yes ()
No ()
Please list the dates, the school was in operation
HAVE YOU EVER HELD A DRIVING SCHOOL INSTRUCTOR A LICENSE ?
HAVE YOU EVER BEEN A DRIVER EDUCATION INSTRUCTOR IN A SECONDARY SCHOOL?
IF YES, WAS THAT LICENSE EVER SUSPENDED OR REVOKED FOR VIOLATION OF THE RULES?
If yes to either instructor question, please list the name of the school
Prior occupations (last 5)
Beginning time period
Ending time period
Please list the dates, the school was in operation Company
I hereby certify that the statements made in this application are true and correct. I also hereby certify that I have received, read, understood LA Administrative Code, Title 55, Part III and will adhere to all rules and regulations contained therein.
________________________________________________________________________________________________________________________
Signature of Instructor
Date
Signature of Owner
Date
Sworn to and subscribed before me on this ________________day of ________________________________________________, 20___________.
________________________________________________________________________________________________________________________________________
Notary Public
Printed Name
Notary ID #
Rev 012013
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- bulletin 746 louisiana standards for state
- initial application for driving school instructor examiner
- louisiana certification and preparation
- how to apply to become a licensed driving school
- certification update application packet teach
- graduates meet the requirements for louisiana teacher
- 2018 louisiana teacher preparation program fact
- practitioner license initial application for pl 2 and
- teacher certification for charter schools
Related searches
- school district application for employment
- dmv documents for driving license
- application for high school enrollment
- apply for driving licence online
- sarathi website for driving licence
- online application for driving licence
- study guide for driving test
- online test for driving permit
- initial disclosures for mortgage loan
- initial treatment for myocardial infarction
- corvette driving school vegas
- application for free school supplies