DTS 101 (02/10/2016)
BUSINESS ENTITY NAME
OWNER'S NAME (print) (last, first, mi, suffix)
BUSINESS ADDRESS CITY STATE ZIP CODE
REPRESENTATIVE FULL NAME (print) (last, first, mi, suffix)
REPRESENTATIVE INFORMATION (authorized to act on behalf of the school)
TITLE (if applicable) TELEPHONE NUMBER
OWNER INFORMATION
EMAIL ADDRESS (if applicable)
DMV CUSTOMER NUMBER
BUSINESS TELEPHONE NUMBER FAX NUMBER (if applicable)
Virginia Driver Training School/Driver Improvement Clinic License
PAYMENT AUTHORIZATION
Purpose: Use this form for payment authorization for driver training school or driver improvement clinic transactions.
Instructions: Do not mail this form. Fax the completed form to the Commercial Licensing Work Center at (804) 367-2019.
PAYMENT AUTHORIZATION
CREDIT CARD (check one)
VISAMASTERCARD
NAME APPEARING ON CREDIT CARD DAYTIME TELEPHONE NUMBER
AMOUNT TO BE CHARGED
$
AMERICAN
EXPRESS
DISCOVER
CREDIT CARD NUMBER EXPIRATION DATE (mm/yy)
TRANSACTION TYPE
Identify the applicable transaction you are completing and fax this completed form to Commercial Licensing Work Center (804) 367-2019.
I authorize DMV to charge the
credit card account listed.
CARDHOLDER NAME (print)
CARDHOLDER SIGNATURE
DATE (mm/dd/yyyy)
ORIGINAL RENEWAL
Driver Training School License
Include school and instructor(s) application and supporting documents.
School Application Instructor(s) Application Change of Address
ORIGINAL RENEWAL
Driver Improvement Clinic License
Include school and instructor(s) application and supporting documents.
Clinic Application Instructor(s) Application Additional Site(s)
Financial Audit
Civil Penalty Driver Improvement Clinic Driver Training School
