Form Des-032 - Driver Education Provider User Id Request/removal - 2009

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DES-032 (2/2009) By Authority of 2006 PA 384
Michigan Department of State (517) 241-6850
Driver Education Provider
User ID Request/Removal Form
The following information is required to obtain or delete a User ID and password for access to the Web-based driver education Segment 1
and Segment 2 knowledge tests. Please be sure all information is legible.
Provider Name (include corporate and/or dba name): ___________________________________________________________________
Street Address: ____________________________________________________
Provider Certification Number: _______________
City: ___________________________________________________________
State: __________
Zip Code: __________________
Use Part A to request User IDs for driver education instructors or staff to access the Web-based knowledge tests.
Use Part B to remove driver education instructors or staff from access to the Web-based knowledge tests.
Part A: My/our organization needs User IDs and passwords for the certified instructors and staff listed below.
Certification
Name
Working Title*
E-mail Address
Number
Part B: My/our organization no longer needs access for the certified instructors and staff listed below.
Certification
Reason (no longer employed,
Name
Working Title*
Number
withdrawing approval for access, etc.)
*Working Title – owner, officer, designated representative, instructor, clerical, etc.
NOTE: Once a person is assigned a User ID and password, it is the responsibility of the provider to ensure that the department’s rules for
use are being followed. For security reasons, you must contact the Department of State when a person who has been assigned a User ID
leaves your organization so that deactivation can be completed.
Certification: I certify that my organization is responsible for ensuring the security of User IDs and passwords issued to its
personnel. I will contact the Department of State immediately if a designated user is no longer employed or allowed to have
access to the Web-based knowledge tests.
___________________________________________________________
_________________________________________
Signature of Owner/Designated Representative/Coordinator
Date
Return completed form to:
Michigan Department of State
Driver Programs Division
Driver Education Section
Lansing, MI 48918

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