Free MV3112 - Driver Instructor Application - Wisconsin

DRIVER INSTRUCTOR APPLICATION
MV3112 2/2009 s.343.62 Wis. Stats.

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Section A - Customer - Please print
Application Type - Check One Original Renewal Duplicate - Complete front only
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 608-264-7495 [email protected]

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

Neatness and accuracy are important since your license will be prepared from the information supplied on this application.
1. Applicant Name (First - Middle Initial - Last) 2. Social Security Number *

3. Current Residence Address

City

ZIP Code

4. Birth Date

5. Sex

6. Mailing Address and/or Post Office Box - ONLY if Different from Residence

7. Current Instructor ID Number

8. Driver License Number

9. Expiration Date

10. State of Issuance

11. Are you a WisDOT employee? No Yes - Give Division and Bureau: 12. List all driving schools where you will instruct. For each driving school, include ID number, complete address, and telephone number. Attach a separate page if more space is needed.

YES

NO

13. In the past 5 years, have you been licensed in another state or Canada? If yes, list location and submit a driving record from there. 14. Have you been associated with a driver school when its license was revoked, suspended, cancelled or denied? If yes, give school name, reason, date and location.

15. Are you employed by, or do you have financial interest in a third party tester for CMV? If yes, give third party tester name, address and telephone number.

16. In the past, have you been convicted of a felony? If yes, give reason, date and location.

17. Are you required to register with the Sex Offender Registry? If yes, give reason, date and location.

18. Are you required to register with the Nurse Aide Registry? If yes, give reason, date and location.

19. Have you had any instructor license revoked, suspended, cancelled, or denied? If yes, give reason, date and location.

20. In the past year, have you had a loss of consciousness or muscle control, caused by any of the following conditions? If yes, check condition(s) and give date . Brain or Head Injury Heart Mental Seizure Disorder Diabetes Lung Muscle or Nerve Stroke

21. I have completed one of the following training programs. Attach copies. (If applying for renewal or duplicate, disregard this question.) 9 Credits in Driver Education DPI Certification 40 Hour Course 22. For renewal only: I have completed the required traffic safety workshop. Yes, Give Date: No 23. I certify that the answers and statements on this application are true and correct. I understand that I may be required to submit additional medical information if requested. I also understand that this application will be denied if I have unpaid taxes or child support. I authorize the examining physician to release my medical history upon request to the Wisconsin Department of Transportation.

(Applicant Signature)

(Date)

(Over)

Print

Section B - Medical Practitioner - Please print
Please answer ALL of the following questions regarding the applicant identified on the other side of this form.

This report must be based on an examination conducted within 90 days of this application. Examination Date - Required
YES NO Alcohol or other drug abuse or dependency within the past 12 months
Alcohol or other drug abuse or dependency within the past 12 - 24 months
Controlled by treatment
Yes
No YES NO Heart surgery (valve replacement/bypass, angioplasty, pacemaker, AICD) Date _______________ Mental/Emotional Functions Diabetes or elevated blood sugar controlled by Diet Kidney disease, dialysis Lung disease, emphysema, asthma, chronic bronchitis
Required oxygen use Pills Insulin YES NO Positive TB in a communicable form
Missing or impaired hand, arm, foot, leg Seizures, epilepsy Episode Date


Neuro/Muscular disease, e.g., ALS, MS, Head Trauma Loss of, or altered consciousness Date __________

Blood pressure over 180/105 Heart disease or heart attack, stroke, other cardiovascular condition


Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring

For any YES answers, indicate onset date, diagnosis, and any current limitations. List all medications (including over-the-counter medications) used regularly or recently.

Yes

No The individual who is requesting this physical is applying to become a licensed driver training school instructor. In a vehicle, he/ she may be instructing, at the same time, up to 3 students that may be under the age of 18. Do you believe this person is physically and mentally capable to act as a driver instructor?

Name of Medical Practitioner - Please Print

Medical License Number

Identify Medical Practice

Area Code - Office Telephone Number

I certify that I have examined this applicant, that the above answers are a result of the examination, and that I am licensed to practice in Wisconsin.
Signature of Reporting Medical Practitioner

Date

X
Section C - Cooperative Driver Training Program (CDTP) or DMV Use
School Name School ID # Highway Signs Pass Fail Instructor Name Driver Training Instructor Test Pass Fail Class D Pass Fail Instructor ID #

Knowledge Tests - 80% or Higher to Pass

Section D - DMV Use Only
CDL Pass Fail Skills Test (MV3543 or MV3544) Fail Pass Oral (MV3222 or MV3717) Pass Fail

Brake Reaction Results

Average of 3 times: At least 50/100 second using portable test Pass Fail

OR

During Skills Test - 1 time Pass Fail

Visual Acuity - 20/40 in one eye (either one) and at least 20/100 in other eye; Temporal Field of Vision of at least 70 0 in EACH eye
Without RX Right Eye Left Eye
COMMENTS

With RX

Temporal Field

Normal Color Perception Yes

No

20/ 20/

20/ 20/

> 70 0 > 70 0

Yes No Yes No

20% Minimum Depth Perception - Able to see sign closest to eye Yes No Hearing - Must be normal Corrected Uncorrected

Date

Place of Examination

Examiner Signature / ID #

Section E - DTS Coordinator Use Only

Driver Record Check

Background Check JUS CIB

CCAP

SOR

NAR