Fillable Form PDS105 Driving Instructor Certification Application

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Form PDS105 Driving Instructor Certification Application

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The Form PDS105 Driving Instructor Certification Application form is 4 pages long and contains:

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  • 2 check-boxes
  • 87 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Driving Instructor Certification Application
Registry of Motor Vehicles Division ● Driver Licensing ● P.O. Box 55889 ● Boston, MA ● 02205-5889
Save time, go to mass.gov/RMV to apply online!
p.1 PDS105_0218
IMPORTANT: This application must be completed, signed and dated. An incomplete application will be returned.
A. Applicant Information
Last Name
First Name
Middle Name
Suffix
Date of Birth (MM/DD/YYYY)
Current Massachusetts Driver’s
License # (if applicable)
Out-of-State Driver’s License #
(if applicable)
What is your Social Security Number?
Residential Address (Where you actually reside)
City State Zip Code
Mailing Address
(same as above)
Street
Apt. #
City
State Zip Code
Email
Phone Type
Phone #
Cell
Home
Work
Emergency Contact Information: (optional)
Email
Name
Phone Type
Phone #
Cell
Home
Work
Employer Information
Employer Name
Employer Email
Phone #
Employer Address
Street
City
State Zip Code
B. Service Type
1. Type:
Professional Driving School Instructor
CDL Instructor School
Public High School Driving Instructor
Driver Skills Development Instructor
2. Application Fees:
New Application $25.00
Renewal Application $25.00 (Public High School Instructors exempt from fees)
C. Mandatory Questions
Have you been charged or convicted of any crime, including motor vehicle violations? ...........................................................................
Yes
No
If yes, provide details: ____________________________________________________________________
Are you currently or have you ever been employed with the Massachusetts Department of Transportation
or Registry of Motor Vehicles Division? ...................................................................................................................................................
Yes
No
If yes, where? ___________________________________________________________________________
Do you have any immediate family members (parents, spouse, children, brothers, sisters) employed with
the Massachusetts Department of Transportation or Registry of Motor Vehicles? ...................................................................................
Yes
No
If yes, where? ___________________________________________________________________________
False statements are punishable under M.G.L. chapter 90 section 24.
Applicant’s Signature: ________________________________________________________________ Date: _______________________
D. Applicant Signature
False statements are punishable under M.G.L. chapter 90 section 24.
Applicant’s Signature: ________________________________________________________________ Date: ______________________________
See reverse for additional required documentation
Street
p.2 PDS105_0218
E. New Application
All Applicants
If you are not a Massachusetts resident or if you have converted an out-of-state license with in the last 5 years, you must provide the following:
•
Photocopy of your out-of-state driver’s license.
•
Original or certified driving record from your home or previous state of residence no more than 30 days old from the date of issue.
•
Documentation of High School Diploma (or College Diploma).
•
CORI Form
If you are a Professional Driving School Instructor, please provide:
•
Documentation of successful completion of a 65 hour Driving Instructor Training Course.
If you are a Public High School Driving Instructor, please provide:
•
Documentation of successful completion of a 65 hour Driving Instructor Training Course.
•
Documentation from high school or school committee on official letterhead confirming current employment as a driving instructor.
If you are a CDL Driving School Instructor, please provide:
•
Documentation of successful completion of a 65 hour Driving Instructor Training Course.
•
Documentation of Division of Professional Licensure.
If you are a Driver Skills Development Program Instructor, please provide:
•
Documentation of 1-year instructor experience at existing DSDP.
•
Documentation of 1-year instructor experience at existing PDS and documentation of acquired skills necessary to instruct a DSDP.
•
Documentation of successful completion of a DSDP Instructor Training Course.
F. Renewal Application
All Applicants
If you are not a Massachusetts resident you must provide the following:
•
Photocopy of your out-of-state driver’s license.
•
Original or certified driving record from your home or previous residence no more than 30 days old from the date of issue.
•
CORI Form
If you are a Public High School Driving Instructor, please provide:
•
Documentation from high school or school committee on official letterhead confirming employment as a driving instructor
Criminal Offender Record Information
(CORI) Acknowledgment Form
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 |
p.4 CORI101_0218
To be used by organizations conducting CORI checks for employment or licensing purposes.
The Massachusetts Registry of Motor Vehicles is registered under the provisions of M.G.L. c.6, § 172 to receive CORI for the purpose of screening
current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, or current licensees.
As a prospective or current employee, subcontractor, volunteer, license applicant or current licensee, I understand that a CORI check will be submitted
for my personal information to DCJIS. I hereby acknowledge and provide permission to the Massachusetts Registry of Motor Vehicles to submit a CORI
check for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any
time by providing the Massachusetts Registry of Motor Vehicles with written notice of my intent to withdraw consent to a CORI check.
I also understand, that the Massachusetts Registry of Motor Vehicles may conduct subsequent CORI checks within one year of the date this Form was
signed by me.
By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this Acknowledgement Form is true and accurate.
__________________________________________________________________________ _______________________________
Signature of CORI Subject Date
p.5 CORI101_0218
A. Applicant Information
Please complete this section using the information of the person whose CORI you are requesting. The fields marked with an asterisk (*) are required.
*First Name
*Last Name
Middle Name
Suffix
Former Last Name #1
Former Last Name #2
Former Last Name #3
Former Last Name #4
*Date of Birth (MM/DD/YYYY)
Place of Birth
*Last SIX digits of Social Security Number (SSN)?
No SSN
Gender
Height (feet, inches)
Eye Color
Race
M
F
Driver’s License of ID Number
State of Issue
Father’s Full Name
Mother’s Full Name
Current Address
* Residential Address (Where you actually reside)
Street
*City
*State
Zip Code
B. Notarization Section – this section must be completed by a notary public
"On this ___ day of _______________ , 20 __ , before me, the undersigned notary public, ________________________________
(name of applicant) personally appeared, proved to me through satisfactory evidence of identification, which were
_______________________, to be the person who signed the preceding or attached document in my presence and who swore or
affirmed to me that the contents of the document are truthful and accurate to the best of (his) (her) knowledge and belief.
Seal of Notary Public
Notary Public Signature __________________________________
Commonwealth of Massachusetts
County of _________________________
Commission Expires: ________________
In.
Ft.
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Form PDS105 Driving Instructor Certification Application

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Completed 12 February 2020

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