Fillable Printable Form MV-523 - Application for Driving School Instructor Certificate - New York

Form MV-523 - Application for Driving School Instructor Certificate - New York

o Original Instructor’s Certificate ($10.00)

o One-Year Renewal ($10.00)

o Two-Year Renewal ($20.00)

o Additional Certificate ($0)

o Classroom Endorsement ($0)

o Change of Vehicle Class Endorsement ($0)

1. Have you had one year or more of experience as an in-car driving school instructor? ................................................................................................. oo

If yes, list name of driving school and the number of hours of instruction you have provided

______________________________________________________________________________________________ Number of hours:_______

2. Have you been compensated for giving driving instruction within the last 12 months? ...............................................................................................

3. Do you have a Driver Education Instructor Certificate (form MV-283)? If yes, attach a copy of the certificate, and write

Certificate (MV-283) number here:________________________ ................................................................................................................................ oo

4. Within the last three years, have you been convicted of any moving violations (other than parking violations)?......................................................... oo

5. Have you ever:

a. had your license to drive (or your driving privilege) refused, cancelled, suspended or revoked in New York or any other state? ........................... oo

b. had a driving school and/or instructor’s certificate denied, suspended or revoked?................................................................................................... oo

c. been a Point & Insurance Reduction Program instructor? If yes, list the name of the delivery agency, and when you taught, below...................... oo

d.been known by any name other than the one shown on this application? If yes, what name? __________________________________________ oo

e.been convicted of a felony, or any crime involving violence, dishonesty, deceit, indecency, degeneracy or moral turpitude?.................................. oo

f. been convicted of perjury, or of making any false statements relating to any part of the New York State Vehicle and Traffic Law?....................... oo

6. Are you presently involved with any charges or court proceedings relating to a DMV matter (including driving school,

Private Service Bureau, PIRP, and/or Vehicle Safety)?..................................................................................................................................................

NOTE: The suspension or revocation or a pending matter in violation of Vehicle and Traffic Law may be due cause for denial of this application.

New York State Department of Motor Vehicles

APPLICATION FOR DRIVING SCHOOL

INSTRUCTOR CERTIFICATE

(Please fill out application completely and print clearly -

this will reduce processing delays.)

www.dmv.ny.gov

CHECK WHAT YOU NEED

All Fees Are Nonrefundable

FOR OFFICE USE ONLY

Instructor Class ______________

Certificate No. ________________________________

Denial No. _____________

o Classroom

Endorsement

Last Name

Mailing Address (Street & No.)

City

Note: Section 5 of the NYS Tax Law requires the Department of Motor Vehicles to provide Social Security numbers to the NYS Department of Taxation and

Finance upon request.

Have you:

u received a high school diploma or GED (General Educational Development)?

(If “Yes,” attach copy if you are an original applicant.) Foreign documents

must be translated by a Civil Service approved organization . . . . . . . . . . . . . . o o

u completed a DMV approved course in traffic safety for driving school

instructors (30-hour basic)? (If “Yes,” attach copy of certificate.)

. . . . . . . . . . . . o o

u completed a DMV approved advanced course in teaching techniques &

methodology? (If “Yes,” attach copy of proof of completion.)

. . . . . . . . . . . . . . . o o

Place of Birth

License Class Expiration Date Years of Driving Experience

Sex

o M

o F

First

State Zip Code

Driver License ID No.

M.I. Social Security Number Date of Birth (Mo./Day/Yr.)

/ /

Date

Issued:

/ /

Expiration

Date:

/ /

Date

Denied:

/ /

EDUCATION - Attach a copy of all credentials, disregard if previously submitted

What type(s) of vehicles will you use for instruction? o Auto o Bus o Motorcycle o Tractor-Trailer o Truck

You must answer ALL the following questions. Questions answered “Yes” must be explained below or on additional page(s).

NAME AND ADDRESS OF LICENSED DRIVING SCHOOL SUBMITTING THIS APPLICATION:

NAME OF PERSON APPLYING FOR A DRIVING SCHOOL INSTRUCTOR CERTIFICATE:

CHECK ONE

YES NO

PAGE 1 OF 2

/ /

____________

/ /

____________

/ /

____________

School

Yes No Date Issued

MV-523 (6/15)

EXPLANATIONS:

If you answered “Yes” to any questions above, give the details below or attach additional page(s). Identify the number of the question being answered.

The applicant agrees that:

FOR OFFICE USE ONLY

o Approved

o Disapproved

By: _____________________________________________________________ Date__________________

Applicant Name: _____________________________________________________

PLEASE ALLOW 6-8 WEEKS FOR PROCESSING

WHAT IS NEEDED: Find the section below that applies to the action you want to take. It lists the documents you must provide with your completed application.

4 All applicable fees should be made payable to the “Commissioner of Motor Vehicles.” Please note that “starter checks” cannot be accepted.

4 AN ORIGINAL INSTRUCTOR CERTIFICATE

u A $10 check or money order payable to the Commissioner of Motor Vehicles

u Two photographs no more than 30 days old

u A copy of the applicant’s high school diploma or General Educational Development (GED)

4 A RENEWAL INSTRUCTOR CERTIFICATE

u For a one-year renewal, send a $10 check or money order payable to the Commissioner of Motor Vehicles

u For a two-year renewal, send a $20 check or money order payable to the Commissioner of Motor Vehicles

u Two photographs no more than 30 days old

u Proof of completion of the 30-Hour Basic Course for the preparation of professional driving school instruction

(THE 30-HOUR BASIC COURSE MUST BE COMPLETED WITHIN A YEAR FROM THE DATE THE ORIGINAL

INSTRUCTOR CERTIFICATE IS/WAS ISSUED)

4 CLASSROOM ENDORSED INSTRUCTOR CERTIFICATE

u Send a copy of the required 30-Hour Basic Course completion certificate

u Send proof of completing an approved advanced program in Teaching Techniques and Methodology

(ONE YEAR OF BEHIND-THE-WHEEL INSTRUCTION WILL ALSO BE NECESSARY FOR CLASSROOM ENDORSEMENT)

MV-523 (6/15)

Mail completed applications to: NYS Department of Motor Vehicles, Bureau of Driver Training Programs, 6 ESP, Room 221, Albany NY 12228.

ATTACH

PHOTO(S)

Photograph(s) must have been

taken within past 30 days and

should be 1 7/8’’ wide x 2’’ long,

and must be a true likeness

showing only the shoulders, neck

and uncovered head.

The applicant agrees that:

1. If I end my employment with the driving school, I will surrender my instructor’s certificate to the school. (the school is required to surrender

the certificate to the DMV).

2. The instructor’s certificate will only be used to give driving and/or classroom instruction in the course of my employment or association with the driving

school identified on this application.

3. If I wish to be employed by an additional driving school, I understand that the school must submit an application for an additional instructor’s certificate.

4. If my driver license is suspended or revoked, either temporarily or indefinitely, I understand that my instructor certificate will immediately become void,

and I must surrender my certificate to the driving school or DMV.

5. If I lose my certificate, I will report the loss to the local police in order to obtain a police report and have my employer submit a request for a duplicate to DMV.

6. I will carry the instructor’s certificate at all times while giving driving instructions or when I am accompanying a student to a DMV road test.

I affirm that I have read this entire application; that I know its contents and that all answers, statements and all other matters contained in it are true.

understand that any false statement will result in the revocation of any driving school instructor’s certificate that has been issued to me.

NOTE: It is

a criminal offense to knowingly make a false statement or conceal a material fact in this application. To do so will result in the revocation of your instructor

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

Applicant’s Signature ç______________________________________________________ Date _____________________________

This application must

be signed by an authorized official of the driving school.

Name of Driving School Official (printed) _______________________________________________________ Title________________________________

Signature of Driving

School Official

ç_______________________________________________________________________________ Date ______________________

PAGE 2 OF 2

Name of Firm

Address of Firm

Kind of Work

Dates Employed

;

From To

Reason for Leaving

Dates Employed

;

From To

Dates Employed

From To

Name of Firm

Kind of Work

Name of Firm

Kind of Work

List employment experience for last 5 years, most recent first.

EMPLOYMENT HISTORY

reset/clear