Fillable Printable Training Instructor Application For License
Fillable Printable Training Instructor Application For License
Training Instructor Application For License
SBTS-612
SBTS-612 (Rev. 2/00)
North Carolina
Division of Motor Vehicles
School Bus and Traffic Safety Section
APPLICATION FOR LICENSE
Commercial Driver Training Instructor
FOR DEPARTMENT USE ONLY
Audit No.
License: 1 2 3 4 5
Issued: License No.
Date Issued
Date Expires
Remarks
This form must be submitted by ALL applicants for a Commercial Driver Training School Instructor’s License.
Name of Applicant
Date of Application
Mo. Day Yr.
Home Address
City
State
Zip Code
Home Phone (Area Code)
Current N.C. Driver License No.
Social Security Number
Business Phone (Area Code)
Place of Birth
City & State
Height
Weight
Color of Eyes
Color of Hair
Sex
Date of Birth
Mo. Day Yr.
EDUCATION AND MILITARY SERVICE
Education (Circle the highest grade completed)
Grade SchoolHigh SchoolCollege
Other(Please specify)
1
23456
78
910111212345
6
Have you successfully completed a course in Driver Education at
an accredited college or university?
Yes No
(If answer is yes complete the following spaces.)
College or University
Location of College or University
City State
Date Course Completed
Do you hold a N.C. Teaching Certificate? Yes No
If so, indicate certificate number
Are you a veteran?
Dates of Service
From/To
Branch of Service
Type of Discharge
Yes No
List name and address of Commercial Driver Training School at which you are (or expect to be) employed:
Name of School
EMPLOYMENT
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List employment experience for last 5 years, most recent first (use additional paper if extra space is needed).
Name of Firm
Address of
Firm
Kind of Work
Dates Employed
Dates of Employment
From/To
Reason for Leaving
Name of FirmAddress of Firm
Kind of Work
Dates Employed
From/To
Reason for Leaving
Name of Firm
Address of Firm
Kind of Work
Dates Employed
From/To
Reason for
Leaving
QUESTIONS
You must answer each of the following questions "Yes" or "No". All questions answered "Yes" must be explained in the explanation area provided on the back side of
application.
1.
Yes No
Have you ever been known by any name other than the one shown on the personal history?
2.
Yes No
Have you ever been convicted of a felony?
3.
Yes No
Have you ever been convicted of murder without malice with a motor vehicle?
4.
Yes No
Have you ever been convicted of negligent homicide?
5.
Yes No
Have you ever been convicted of driving under the influence of intoxicating liquors?
6.
Yes No
Have you ever been convicted of driving under the influence of drugs?
7.
Yes No
Have you ever been convicted of leaving the scene of a traffic accident involving death or personal injury?
8.
Yes No
Have you ever been convicted of perjury or making of any false statements relating to any portion of the
N.C. Motor Vehicle Law?
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9.
Yes No
Have you ever been convicted of any traffic violations other than parking violations?
10.
Yes No
Have you ever convicted of any crime involving moral turpitude?
11.
Yes No
Have you ever been convicted of any misdemeanor other than traffic violations?
12.
Yes No
Are you now involved with any charges or court proceedings relating to the matters stated in questions2, 3, 4, 5, 6, 7, 8, 9, 10, or 11?
13.
Yes No
Has your license to drive in N. C. or any other state, ever been refused, cancelled, suspended, or revoked?
14.
Yes No
Has your commercial driver training school instructor’s license ever been denied, cancelled, suspended, or revoked?
15.
Yes No
Are there any motor vehicle accident judgments pending against you as yet unsatisfied?
16.
Yes No
Have you given driver training instruction for compensation or hire within the past 12 months?
Explanation of the previous questions answered "Yes"
INSTRUCTOR TRAINER LICENSE APPLICATION
To be filled out only by those applying for certification as trainers of instructors. See Rules and Regulations, Section .0501(c).
EXPERIENCE: I certify that I have worked as an active, licensed instructor in driver education for the following schools:
__________________________________________________________________________________________________________
SCHOOL CITY & STATE DATES WORKED
__________________________________________________________________________________________________________
SCHOOL CITY & STATE DATES WORKED
OBSERVATION: Classwork Observation Conducted (2 hrs.) DATE/S
Roadwork Observation Conducted (2 hrs.) DATE/S
RECOMMENDATION:
DRIVER EDUCATION SPECIALIST
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Attached is a check in the amount of $8.00 to cover processing fees for this certification.
The undersigned swears (affirms) that he has read the entire foregoing personal history schedule; that he knows the contents thereof; and that all answers,
statements and all other matters contained therein are true in substance and in fact.
_________________________________________
Applicant’s signature
TO KNOWINGLY MAKE A FALSE STATEMENT OR CONCEAL A MATERIAL FACT IN THE APPLICATION IS A CRIMINAL OFFENSE, AND MAY RESULT IN THE REVOCATION OF
YOUR COMMERCIAL DRIVER TRAINING SCHOOL LICENSE.
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