Application to instruct - Minnesota



CHILDREN AND RESTRAINT SYSTEMS TRAINING C.A.R.S.APPLICATION TO INSTRUCTChoose One: [ ] CPS Technician [ ] CPS Technician InstructorApplicant InformationName: Agency: Address: City, State, Zip: County: Phone: E-mail: Position or Program: National Certification InformationTechnician or Technician Instructor Certification Number: Expiration Date: Instructor AgreementI am a certified Child Passenger Safety Technician or Technician Instructor in good standing and do hereby agree to adhere to the course content and procedures set forth by the Minnesota Department of Public Safety when performing my duties related to the Minnesota Child Passenger Safety Instructor Guidelines. Failure to comply with these procedures or guidelines may result in my certification being suspended or revoked.I understand that my information will be shared with child car providers seeking instruction in the Minnesota Children and Child Restraints – C.A.R.S. training.Applicant signature: Date: Please check the following if you need the Instructor CD sent to you: [ ]Mentor InformationName and CPST # of C.A.R.S. training instructor who mentored you:Printed Name: ID# I certify that the above applicant has successfully completed the requirements necessary to become an instructor of the Minnesota Children and Restraint Systems courseSigned: Date: RETURN COMPLETED FORM TO:Minnesota Child Passenger Safety ProgramMinnesota Department of Public Safety – Office of Traffic Safety445 Minnesota Street, Suite 150Saint Paul, MN 55101-5150Fax: 651-297-4844 ................
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