Classroom Student Record and Completion Form
DE-003A
(08-17)
First Name Middle Last Phone #
Street Address
City
County
State
Zip Code
Name of Driving School Branch Location School #
Date of Birth Age (
at the time class started)
Date
Start End Hours Unit Inst. Inst. Test
Time Time Initials ID# Score *
* Answer sheets must be attached.
I certify under penalty of perjury, that the above information is true and correct to the best of my knowledge, information and belief.
Authorized School Official’s Signature Date
Students Full Signature Date
White Copy - MVA Canary Copy - School Pink Copy - Student
Complete all requested information and signatures in full
6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062
For more information visit our website at www.mva.maryland.gov, call 410-768-7000 or TTY for the hearing impaired: 1-800-492-4575.
