Fillable DRIVER SCHOOL APPLICATION (Wisconsin)

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DRIVER SCHOOL APPLICATION (Wisconsin)

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DRIVER SCHOOL APPLICATION
Wisconsin Department of Transportation
MV3110 3/2018 s.343.60 -.72 Wis. Stats.
Driver Training School Coordinator dotdrvrtrnschool@dot.wi.gov
Section A – Customer (please print)
APPLICATION TYPE (check one) Original Renewal Duplicate Change
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 Refresher 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
Complete all questions. Questions not answered will delay license issuance. For original and renewal licenses, submit this application with
required documents. Refer to MV3757 for further information.
1. School Name (exactly as it is to appear on license)
2. School ID # (DMV Assigned)
1
2
3
4
5
6
7
8
4. Current Office Address, City, State, ZIP Code
County
5. Special Mailing Address (if different from above address)
6. Email Address
7. List all classrooms to be used. Include complete address. (if applicable)
8. Type of Ownership
Sole Proprietorship Partnership Corporation
9. Corporate or Firm Name (if other than the school
named above)
10. Federal Employer ID Number (FEIN)
–
1
2
3
4
5
6
7
8
9
11. List all owners, partners, associates, officers, directors, managers (Owners/Managers–Online Only)
IF WisDOT EMPLOYEE
GIVE DIV/BUR
B
C
TITLE
FULL NAME
BIRTH DATE
SEX
* SOCIAL SECURITY #
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. List all driver training vehicles owned or leased by your school. Attach a separate list if additional space is needed. (if applicable)
YEAR
MAKE
IDENTIFICATION NUMBER
LICENSE PLATE NUMBER
17. List all instructors. Give first name, middle initial, last name and instructor license number. Attach a separate list if additional space is needed.
Wisconsin Department of Transportation
Division of Motor Vehicles
WisDOT Driver Training School Program
P.O. Box 7920, Madison, WI 53707-7920
Telephone: (608) 264-7495 / Fax: (608) 223-7705
Clear Form
DRIVER SCHOOL APPLICATION (continued)
Wisconsin Department of Transportation MV3110
18. Records
YES
NO
Does the school maintain records according to Trans 105.05 and s.343.71(1m) Wis. Stats.?
19. Program Approval – Students Under 18
(if applicable)
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
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?
20.
Is the school CDTP certified?
21. 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 completions electronically submitted in previous 24 months
(if applicable)
:
0–300
301–1100
1101 or More
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.
X
(Authorized School Representative Signature)
(Date – m/d/yyyy)
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
INSTRUCTOR TEST
PASS
FAIL
PASS
FAIL
X
(Date – m/d/yyyy)
(Place of Examination)
(Examiner Signature / ID Number)
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DRIVER SCHOOL APPLICATION (Wisconsin)

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Completed 2 August 2020

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