Free MV3110 Driver School Application - Wisconsin

DRIVER SCHOOL APPLICATION
MV3110 8/2007 s.343.60-.72 Wis. Stats.

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Section A - Customer - Please print
Application Type - Check One Original Renewal Duplicate Reason for Duplicate License Type - Check all that apply Adult only Under 18 only Adults and under 18 Commercial Motor Vehicle (CMV) Telephone: E-mail:

Wisconsin Department of Transportation PO Box 7920 Madison WI 53707-7920 608-264-7049 [email protected]

* The social security number may be used for purposes authorized by law.

Complete all questions. Questions not answered will delay license issuance. For an original license, submit this application with a copy of your insurance policy, insurance bond, contract/agreement, fee schedule and self-certification of your office/classrooms on MV3683 and MV3684.
1. School Name - Exactly as it is to appear on license 2. School ID # (DMV Assigned) 3. Area Code - Telephone Number - Business

4. Current Office Address

City

ZIP Code

5. Special Mailing Address if different from above address

6. E-Mail Address

7. List all classrooms to be used. Include complete address.

8. Type of Ownership Sole Proprietorship Partnership Corporation

9. Corporate or Firm name if other than the school name shown above

10. Federal Employer Identification Number (FEIN)

11. List all owners, partners, associates, officers, directors, managers

TITLE

FULL NAME

BIRTH DATE

SEX SOCIAL SECURITY # *

IF WISDOT EMPLOYEE GIVE DIV / BUR

YES

NO

12.Have any of the above-named persons been associated with a driver school which had its license revoked, suspended, cancelled or denied? If yes, give the person's name, school name, date and location.

13.Do any of the above-named persons have a financial interest in a third party tester or have any been employed by a third party tester for CMV? If yes, give the person's name, third party tester name and address. 14.Have any of the above-named persons been convicted of a felony? If yes, give the person's name, reason, date and location. 15.Are any of the above-named persons required to register with the Sex Offender Registry? If yes, give the person's name, reason, date and location. 16.Are any of the above-named persons required to register with the Nurse Aide Registry? If yes, give the person's name, reason, date and location. 17.List all driver training vehicles owned or leased by your school. Attach a separate list if additional space is needed. YEAR IDENTIFICATION NO. LICENSE PLATE NO. MAKE

18.List all instructors. Give first name, middle initial, last name, and instructor license number. Attach a separate list if additional space is needed.

19.Provide names and signatures of all persons who are authorized to sign agreements, driver school certifications (MV3192) and school certifications of enrollment on form MV3001. Attach a separate page if more space is needed.

(Print Name)

(Signature)

(Date)

(Print Name)

(Signature)

(Date)

(Print Name)

(Signature)

(Date)

20. Records
YES NO

Does the school maintain records according to Trans 105.05 and s.343.71(1m) Wis. Stats.? 21. Program Approval - Students Under 18
YES NO Classroom and Behind the Wheel

Does the classroom and behind-the-wheel lesson plan summary specify a minimum of one main topic or more for each hour? Do the classroom and behind-the-wheel lesson plans extend over a minimum of 3 weeks? Classroom Does the course cover, but is not limited to, the specific items listed in Trans 105.07 and s.343.71(5) Wis. Stats.? Does the lesson plan cover no more than 2 hours per day, excluding breaks? Does the instruction consist of a minimum 30 clock hours per student? Behind-the-Wheel Check the appropriate lesson plan(s) which you will be teaching. 7/4 8/2 9/0 6/6 Will each student have no more than 1 hour of behind-the-wheel driving per day? Will each student observe no more than 2 hours per day? 22. Insurance/Bond Requirements per s.343.61 Wis. Stats. and Trans. 105.10 Proof of Insurance attached Proof of Bond attached - Specify Amount

Number of Signed Completion Slips in previous 24 months 301-1100 0-300

1101 or more

23. I certify that the answers and statements on this application are true and correct. I understand that the school and instructor license applications will be denied if an applicant has unpaid taxes or child support.

(Authorized School Representative Signature)

(Date)

Section B - DMV Use Only - School Owner/Manager Tests - 80% or Higher to Pass - Attach a separate page if more space is needed.
SCHOOL OWNER / MANAGER NAME SCHOOL TEST PASS FAIL INSTRUCTOR TEST PASS FAIL

Date

Place of Examination Driver Record Check

Examiner Signature / ID # Background Check CIB JUS 40 Hour Instructor Training

Section C - DTS Coordinator Use Only
Lesson Summary B-T-W 6/6 7/4 8/2 9/0

CCAP Refresher

SOR Internet

NAR

Classroom

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