Fillable Printable Form DPR-102 - Drinking Driver Program Instructor Application - New York

Form DPR-102 - Drinking Driver Program Instructor Application - New York

Address

New York State Department of Motor Vehicles

DRIVERPROGRAMREGULATION- CUSTOMERSERVICEUNIT

www.nysdmv.com

DRINKING DRIVER PROGRAM

INSTRUCTOR APPLICATION

DPR-102 (3/06)

*DPR-102*

Client ID Number

(ID Number from NYS Driver License)

TO BE QUALIFIED AS ANEW YORK STATE DRINKING DRIVER PROGRAM INSTRUCTOR, YOU MUST:

hold a driver license valid for operation in New York State;

have no record of suspension or revocation of the driver license for a period of at least three years prior to instructing in the

Drinking Driver Program;

not be employed or retained by an alcoholism and substance abuse evaluation/treatment provider where DDP participants

are referred; and

have at least two years of full-time professional experience as a group counselor, preferably in alcohol or drug abuse

counseling, OR two years of teaching experience.

Date of Birth (Month-Day-Year)

Sex

M F

City

Address (Continued)

Last Name of DDP Instructor Applicant

Suffix (Jr., Sr., etc.)

First Name

Middle

Initial

State

Zip Code

Driver

License State

Driver License Expiration Date

If state of driver license is not New York, the applicant must attach a recent certified driver’s license abstract from the state of

license record.

PAGE 1 OF 2

ACTION WANTED:

Original

Lack of Experience

Conflict of Interest

Driver License Record

Denied:

Amendment

OFFICE USE ONLY

I attest to the fact that I have at least two years experience required to be a DDP Instructor, and am not employed or

retained by an alcoholism and substance abuse evaluation/treatment provider where DDP participants are referred.

Signature of ApplicantDate Signed

➧

Address of DDP Program Site

DDPAddress (Continued)

Drinking Driver Program Name (Instructor Employer)

City

State

Zip Code

Drinking Driver Program Director Last Name

DDP Director First Name

Signature of DDP DirectorDate Signed

➧

Complete and mail all application materials to:

New York State Department of Motor Vehicles

Driver Program Regulation

6 Empire State Plaza, Room 412

Albany, NY12228

PAGE 2 OF 2

Suffix (Jr., Sr., etc.)

Middle

Initial

DPR-102 (3/06)

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