Fillable Printable Form DTP-422 - DMV's 30-Hour Basic Instructor's Course Notice - New York

Form DTP-422 - DMV's 30-Hour Basic Instructor's Course Notice - New York

NOTICE OF ENROLLED, COMPLETED, AND DROPPED STUDENTS

OF DMV’S 30-HOUR BASIC INSTRUCTOR’S COURSE

DRIVER TRAINING PROGRAMS

DTP-422 (9/15)

Name of Enrolled Student

Client ID #

Student’s Instructor

Certificate #

Date Student

COMPLETED

the Course

Date Student

DROPPED

the Course

COURSE SCHEDULE

Submit this form to DMV prior to the start date of the course, listing the names and client ID# of the enrollees. Then after the course is completed, complete the remaining

columns. (See form DTP-400 for more details on how to fill out this form.) Send form to New York State Department of Motor Vehicles, Bureau of Driver Training

Programs, 6 Empire State Plaza, Room 221, Albany, NY 12228.

Print Name of Owner or Corporate Officer

First Submission:

Date

Signature of Owner or Corporate Officer

I certify that all information and other matters contained herein are true in substance and in fact. Part 76.23(a)(5) of Commissioner’s Regulations authorizes

the Department of Motor Vehicles to suspend or revoke a driving school license for “the failure of the license for any partner, officer, agent or employee of the

licensee to conduct the prescribed tests for instructor applicants in the manner authorized by this department and/or the failure of the licensee or any partner,

officer, agent or employee of the licensee to conduct the 30-hour course to instructor applicants according to the curriculum supplied by this department

and/or for the number of hours required by this department and this part.”

Print Name of Owner or Corporate Officer

FINAL Submission:

Date

Signature of Owner or Corporate Officer

Driving School Offering Course: ______________________________________

Date of First Session: ____________________

AMENDED ON: __________________________________

Name of Instructor: __________________________________

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