Fillable Printable Form MV-285R - Student MV-285 Roster - New York

Form MV-285R - Student MV-285 Roster - New York

STUDENT MV-285 ROSTER

(Please Print or Type)

Certificate No. Date of Birth

To knowingly make a false statement or conceal a material fact in this Student MV-285 Roster is a criminal offense.

False statements are punishable under Section 210.45 of the Penal Code.

_______________________________________________ ______________________________ ____________________

Mail completed roster to: NYS Department of Motor Vehicles

Utica Processing Center

MV-285/MV-278

207 Genesee Street

Utica, NY 13501

Telephone (315) 793-2615

Last Name, First Name, Middle Initial and

Address of Student

Class

Hours

Total

Hours

Duplicate

Certificate No.

and Date Issued

Student’s Client

ID Number

(if available)

Laboratory Hours

Behind the

Wheel

Observation Simulation Range

Numerical Grade

Received

Behind the

Wheel

Classroom

Name of School

Address (Number and Street) City State Zip Code

Telephone Number (include area code)

( )

Signature of Superintendent or Principal

Contact Person Dates course was offered:

From: / / To: / /

Date certificates were issued:

/ /

MV-285R (10/15)

Signature of Approved MV-283 Lecture Teacher Instructor Certificate Number

Date

/ /

(If multiple Lecture Teachers are employed, only Lead Teacher Signs)