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

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

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
DRIVER PROGRAM REGULATION - CUSTOMER SERVICE UNIT
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 A NEW 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 Applicant Date Signed
Address of DDP Program Site
DDP Address (Continued)
Drinking Driver Program Name (Instructor Employer)
-
City
State
Zip Code
Drinking Driver Program Director Last Name
DDP Director First Name
Signature of DDP Director Date 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, NY 12228
PAGE 2 OF 2
Suffix (Jr., Sr., etc.)
Middle
Initial
DPR-102 (3/06)
reset/clear
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