Fillable DRIVER INSTRUCTOR APPLICATION (Wisconsin)

Fill Online, Printable, Fillable, Blank DRIVER INSTRUCTOR APPLICATION (Wisconsin) Form

Use Fill to complete blank online WISCONSIN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

DRIVER INSTRUCTOR APPLICATION (Wisconsin)

On average this form takes 18 minutes to complete

The DRIVER INSTRUCTOR APPLICATION (Wisconsin) form is 1 page long and contains:

  • 0 signatures
  • 24 check-boxes
  • 60 other fields

Country of origin: US
File type: PDF

BROWSE WISCONSIN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
DRIVER INSTRUCTOR APPLICATION
Wisconsin Department of Transportation
MV3112 5/2018 s.343.62 Wis. Stats.
WisDOT Driver Training School Program
P.O. Box 7920, Madison, WI 53707-7920
Telephone: (608) 264-7495
Section A – Customer (please print)
APPLICATION TYPE (check one) Original Renewal Duplicate
LICENSE TYPE Adult Only Under 18 Only Adults and Under 18 Commercial Motor Vehicle Online FYR Only
COURSES APPLYING FOR Classroom 6/6 Behind-the-Wheel 9 Hours BTW Adults Only Online
Failure to Yield (choose one of the following): Classroom Online Both
Instructor Training (choose one of the following): Public Private Both
CMV
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. Current Instructor ID Number
3. Instructor (Area Code) Telephone Number
4. Current Residence Address
City
ZIP Code
5. Birth Date
6. Mailing Address and/or Post Office Box - ONLY if Different from Residence
7. Social Security 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 Have you been associated with a driver school when its license was revoked, suspended, cancelled or denied?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
Heart
Ment
al
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.)
40 Hour Course
DPI Certification
9 Credits in Driver Education
22. For renewal only: I have completed the required traffic safety workshop.
No
Yes, give date, location, and facilitator/organizer:
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
.
X
(Applicant Signature)
(Date – m/d/yyyy)
(Over)
1
2
3
4
5
6
7
8
9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
D
D
Y
Y
Y
Y
M
M
Clear Form
Print
Section B – Health Care Practitioner (please print)
Based on an examination conducted within the previous 24 months, please answer ALL of the following questions regarding the applicant on this form.
Examination date: (Required)
YES
NO
YES
NO
YES
NO
Alcohol or other drug abuse
or dependency within the
past 12 months
Heart surgery
(valve replacement/bypass,
angioplasty, pacemaker, AICD)
Loss of, or altered
consciousness
Date:
Episode
Date:
Alcohol or other drug abuse
or dependency within the
past 12 – 24 months
Date:
Seizures, epilepsy
Kidney disease, dialysis
Sleep disorders, pauses in breathing while
asleep, daytime sleepiness, loud snoring
Controlled by treatment?
Yes No
Diabetes or elevated blood sugar
controlled by
Diet Pills Insulin
Positive TB in a
communicable form
Neuro/Muscular disease,
e.g., ALS, MS, Head Trauma
Heart disease or heart
attack, stroke, other
cardiovascular condition
Lung disease, emphysema,
asthma, chronic bronchitis
Blood pressure over 180/105
Missing or impaired hand, arm, foot, leg
Required oxygen use
Mental/Emotional Functions
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, 4 students who may be under the age of 18 [Wis. Stat. 343.07(1g)(a)(1)].
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.
X
(Reporting Medical Practitioner – Signature)
(Date – m/d/yyyy)
Section C – Cooperative Driver Training Program (CDTP) or DMV Use
School Name
School ID Number
Instructor Name
Instructor ID Number
Knowledge Tests – 80% or higher to pass
Highway Signs
Pass Fail
Driver Training Instructor Test*
Pass Fail
Class D*
Pass Fail
Section D – DMV Use Only
CDL
Pass Fail
Skills Test (MV3543 or MV3544)
Pass Fail
Oral (MV3222 or MV3717)
Pass Fail
Brake Reaction Results Skills Test – 1 time*
Pass Fail
Visual Acuity – Must be at a minimum of 20/40 in one eye and 70 degrees field of vision in one eye, otherwise, additional vision information will be
required prior to approval.
Without RX
With RX
Temporal Field
Right Eye
20/
20/
> 70
°
Yes
No
Normal Color Perception
Yes
No
Left Eye
20/
20/
> 70°
Yes
No
Hearing – Must be normal
Corrected
Uncorrected
Comments
X
(Date – m/d/yyyy)
(Place of Examination)
(Examiner Signature / ID Number)
Section E – DTS Coordinator Use Only
Driver Record Check
Background Check
CIB
JUS
CCAP
SOR
NAR
*Class D – Instructor Only
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

DRIVER INSTRUCTOR APPLICATION (Wisconsin)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document