LOUISANA DEPARTMENT OF PUBLIC SAFETY & CORRECTIONS

Office of Motor Vehicles

 

Commercial Driving School Instructor Application

Please attach $10 Money Order, Cashier’s Check or Business Check for 38 hour Course Instructor

 

 

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NAME OF DRIVING SCHOOL                                                                                                                            PHONE NUMBER

 

 

DRIVING SCHOOL MAILING ADDRESS

 

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CELL PHONE #                                                        FAX NUMBER                                                        E-MAIL ADDRESS

        

INSTRUCTOR NAME                                                                                                        DATE OF BIRTH                               DRIVER’S LICENSE NUMBER

 

INSTRUCTOR HOME ADDRESS

 

 

List below all physical locations at which you will be required to teach and check the appropriate duty to be performed.

Physical Location	6 hr Instructor	38 hr Instructor	Both 6 & 38 hr Instructor	38 hr Driver Instructor only

 

HAVE YOU EVER BEEN ARRESTED, DETAINED, CHARGED, INDICTED OR SUMMONED TO ANSWER AND APPEAR FOR ANY CRIMINAL OFFENSE, EXCLUDING MINOR TRAFFIC CITATIONS, IN THIS STATE OR ANY OTHER STATE?          YES                    NO     IF YES, LIST ALL REQUIRED INFORMATION BELOW.  YOU MUST INCLUDE CERTIFIED COPY OF COURT DISPOSITIONS ON ALL OFFENSES AND CONVICTIONS.  FAILURE TO INCLUDE ALL INFORMATION AND RECORDS WILL RESULT IN DELAY OR DENIAL OF YOUR APPLICATION.                                                         Offense/Conviction               Date of Offense/Conviction       City, State              Disposition (Attach certified copy of court disposition)         Fingerprints must be submitted for a background check.  See attached fingerprint instructional letter and forms.

I hereby certify that the statements made in this application are true and correct. I also hereby certify that I have received, read, understood and will adhere to all rules and regulations in accordance with La. Administrative Code, Title 55, Part III.

 

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Signature of Instructor                                                                                                                                                              Date

 

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Signature of Owner                                                                                                                                                                    Date

 

Sworn to and subscribed before me on this  day of ,  20.

 

Notary Public ____________________________________________________________________________________________________________