Fillable CLASSROOM INSTRUCTION ATTENDANCE ROSTER (Virginia Department of Motor Vehicles)

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CLASSROOM INSTRUCTION ATTENDANCE ROSTER (Virginia Department of Motor Vehicles)

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HP 17 (01/01/2014)
INSTRUCTOR FULL LEGAL NAME (print) (last) (first) (mi) (suffix)
EVDT SITE ADDRESS
CLASS DAY
OPERATION HOURS
ESCORT VEHICLE DRIVER TRAINING SITE
CLASSROOM INSTRUCTION ATTENDANCE ROSTER
GENERAL INFORMATION
AM PM
Monday Sunday Saturday Friday Thursday Wednesday Tuesday
PM AM
DRIVER'S LICENSE
NUMBER
(as it appears on the license)
NAME
(last, first, mi, suffix)
REASON
CODE
BIRTH
DATE
(mm/dd/yyyy)
ISSUE
STATE
CERTIFICATION
By signing this document, I certify that I am an instructor and designated representative of the escort vehicle driver training site and that the person(s)
named above attended and satisfactorily completed the 8-hour escort vehicle driver training course on the date and time indicated above. I understand the
submission of false or inaccurate information on this attendance roster may result in suspension, cancellation or termination of the site's and instructor's
certificate and the assessment of civil penalties.
I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that
the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I
understand that knowingly making a false statement or representation on this form is a criminal violation.
Purpose: Use this form to document student attendance at the 8-hour Escort Vehicle Driver Training (EVDT) course.
Instructions: Type or print in black or blue ink. Total number of students and sign the certification statement. Authorized Extranet
users must electronically submit this Classroom Instruction Attendance Roster, HP 17 to DMV within 24 hours of course
completion. Maintain a copy of the roster in the EVDT site's files.
STUDENT INFORMATION
EVDT SITE NAME EVDT CODE
SITE CODE
START TIME END TIME
DATE (mm/dd/yyyy)
CITY STATE
ZIP CODE
INSTRUCTOR NAME (print) INSTRUCTOR NAME (print)
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
EVDT
TOTAL NUMBER
OF STUDENTS
DATE (mm/dd/yyyy)
COMPLETION DATE (mm/dd/yyyy)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
HP 17 (01/01/2014)
Escort Vehicle Driver Training (EVDT) sites are required to conduct 8 full hours of instruction, excluding meals and breaks, prior to the
issuance of a certificate of completion.
EVDT Site Name: full name of the site as it appears on the DMV-issued certificate.
EVDT Code: DMV- assigned code as it appears on the DMV-issued certificate.
Date: date the form is completed.
Instructor Name: full legal name of instructor who conducted the instruction.
Site Code: DMV-assigned code for the site where the instruction was conducted.
EVDT Site Address: address of the training site location.
Class Day: day of the week the classroom instruction was conducted.
Operation Hours:
Beginning Time - exact time the classroom instruction began.
Ending Time - exact time the classroom instruction ended.
Completion Date (mm/dd/yyyy): date the instruction was completed.
Driver's license Number: as it appears on the student driver's license.
Issue State/: abbreviation of state that issued license.
Name: student's full legal name, no abbreviations.
Birth Date: student's birth date.
Reason Code: use EVDT if not preprinted on form.
Total Number of Students: total number of students.
Instructor Signature: classroom instruction signs full legal name.
Page 3
INSTRUCTIONS
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CLASSROOM INSTRUCTION ATTENDANCE ROSTER (Virginia Department of Motor Vehicles)

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Completed 2 November 2020

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