Fillable INSTRUCTOR APPLICATION (Virginia Department of Motor Vehicles)

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INSTRUCTOR APPLICATION (Virginia Department of Motor Vehicles)

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HP 505 (01/07/2014)
DRIVER LICENSE NUMBER (as it appears on license)
ESCORT VEHICLE DRIVER TRAINING
INSTRUCTOR APPLICATION
Purpose: Use this form to apply to be an escort vehicle driver training instructor.
Instructions: Submit the completed application to the Commercial Licensing Work Center at the address above.
APPLICANT INFORMATION
INSTRUCTOR CERTIFICATION
I hereby make application to be an escort vehicle driver training instructor and certify that all information contained in this application and on all supporting
document(s) is true and, I authorize the Department of Motor Vehicles (DMV) to verify that my driving record fulfills the requirements for approval under
established criteria, statutes and the Instructor Agreement on the back of this form. I also certify that I will comply with the conditions of the Escort Vehicle
Driver Training Program.
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.
I certify that the above named applicant has applied to become an instructor or is currently an instructor for this escort vehicle driver training business entity.
and has successfully completed an escort vehicle driver certification train-the-trainer session.
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.
TRAINING SITE INFORMATION
TRAINING SITE CERTIFICATION
APPLICANT/INSTRUCTOR FULL LEGAL NAME (print) (last) (first) (mi) (suffix)
TELEPHONE NUMBER STATE (that issued license)
MAILING ADDRESS
EMAIL
BUSINESS ENTITY FULL NAME
BUSINESS OWNER(S) FULL LEGAL NAME
BUSINESS OFFICE STREET ADDRESS
EMAIL
CELL PHONE NUMBER (if applicable)FAX NUMBER TELEPHONE NUMBER
INSTRUCTOR NAME (print)
BUSINESS OWNER NAME (print)
CITY
ZIP CODECITY
INSTRUCTOR SIGNATURE
BUSINESS OWNER SIGNATURE
DATE (mm/dd/yyyy)
LICENSE EXPIRATION DATE (mm/dd/yyyy)
DATE (mm/dd/yyyy)
STATE
ZIP CODE
STATE
( )
( )
( )
( )
HP 505 (01/07/2014)
The Department of Motor Vehicles (hereafter referred to as "DMV") and __________________________________________________________ (hereafter
referred to as Instructor), mutually agree to the following:
CERTIFICATION AND SIGNATURES
By signing this document, I agree to the terms and the conditions specified above. This agreement shall become effective upon signing. Either party may
terminate this Agreement by giving written notice within 30 working days of the termination. I understand that failure to comply with any of the terms of this
agreement may result in termination of the escort vehicle driver training business entity's or instructor's certification.
I certify that I have successfully completed an escort vehicle driver training train-the-trainer session presented by the business entity identified on the reverse
side of this agreement.
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.
ESCORT VEHICLE DRIVER TRAINING
Instructor Agreement
To apply, Instructor must:
1. Submit a completed application.
2. Hold a valid driver's license that reflects no more than 6 demerit points. If the driver's license is out-of-state, submit
a certified copy of a driver transcript from the issuing state to DMV.
3. Hold a valid instructor certification issued by DMV that is associated with the escort vehicle driver training site both at the
time of licensing and throughout the licensure period.
Instructor Requirements for Class Instruction:
1. Follow the curriculum and properly utilize the training materials provided by DMV.
2. Conduct a full 8-hour course of classroom instruction. Meals and other breaks will not count towards the 8-hour
requirement.
3. Issue the appropriate Certificate of Completion to each student successfully completing the course.
4. Report escort vehicle driver training attendance to the site owner within 24 hours of course completion.
Notification of Change Requirements:
1. Instructor must provide written notice to DMV within thirty business days if there are changes that will affect the instructor's
record with DMV.
Additional Limitations:
1. Instructor cannot use the DMV logo on any form of advertising.
2. School advertisements cannot be placed in the DMV Customer Service Centers.
3. If the instructor's certification with DMV expires, that instructor will not be permitted to continue instructing students.
INSTRUCTOR NAME (print) INSTRUCTOR SIGNATURE
DATE (mm/dd/yyyy)
( )
( )
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INSTRUCTOR APPLICATION (Virginia Department of Motor Vehicles)

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Completed 2 November 2020

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