Fillable Printable Application For Driver Education Program Approval

Application For Driver Education Program Approval

PS36010-02 (11/12)

(OVER)

Name of School Business Phone County

Street Address of School

City State Zip Code

Fax Number

Email Address (required)

***Attach an outline of the classroom and/or behind the wheel curriculum if this application is for a new driver education program.***

List All Instruction Locations Address (Street, City, State, Zip code) Business Phone

Zip CodeStateCity

Mailing Address (if different)

All Classes of Motor Vehicle Training Provided: (CHECK ALL THAT APPLY)

Class D Class A Class B Class C Motorcycle Motorized Bicycle

Classroom Classroom Classroom Classroom Classroom Classroom

Simulation Laboratory Laboratory Laboratory Laboratory

Range

On-Street

MINNESOTA DEPARTMENT OF PUBLIC SAFETY

DRIVER AND VEHICLE SERVICES

APPLICATION FOR DRIVER EDUCATION PROGRAM APPROVAL

Print Form

Driver Education Instructors (attach additional sheet if necessary)

Signature of person authorized to sign certificates of enrollment and completion (only one signature may be filed).

Signature of School Principal or Superintendent

Date

Return completed application to Driver and Vehicle Services:

Driver & Vehicle Services

Office of Driver Education

445 Minnesota Street, Suite 176

St. Paul, MN 55101-5176

Fax (651) 296-5316

PS36010-02 (11/12)

Name(s) of Classroom

Instructor(s)

Name(s) of Laboratory

Instructor(s)

Driver's License Number(s)

(Out of state residents must provide certified driving record)

Minnesota Teaching License

Folder Number(s)

Classroom Fee Behind the Wheel Fee Other

Under 18 Years Old

Adult

Other

List Maximum Fees and Charges (required Minnesota Rules Part 7411.0210)

PLEASE NOTIFY THIS OFFICE, IN WRITING, OF ANY CHANGE OF SIGNER AND ANY DELETIONS AND/OR ADDITIONS OF INSTRUCTORS AS THEY OCCUR.

Authorized Signature

Full Printed or Typed Name