Form Mv-523 - Application For Driving School Instructor Certificate
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2FOR OFFICE USE ONLY
WHAT DO YOU NEED?
o
o
Original Instructor’s Certificate
Classroom
Instructor Class ______________
o
Endorsement
Instructor’s Certificate Renewal
Certificate No. ________________________________
APPLICATION FOR DRIVING SCHOOL
o
Additional Certificate
Date
Expiration
o
/
/
/
/
INSTRUCTOR CERTIFICATE
Issued:
Date:
Classroom Endorsement
o
Date
Change of Vehicle Class Endorsement
/
/
Denial No. _____________
Denied:
(Please fill out application completely and print clearly -
this will reduce processing delays.)
dmv.ny.gov
NAME OF PERSON APPLYING FOR A DRIVING SCHOOL INSTRUCTOR CERTIFICATE:
o
Last Name
First
M.I.
Social Security Number
Date of Birth (Mo./Day/Yr.)
Sex
M
o
/
/
F
Mailing Address (Street & No.)
Place of Birth
Driver License ID No.
City
State
Zip Code
License Class Expiration Date
Years of Driving Experience
o
o
o
o
o
Which of the following vehicle type(s) will you teach in?
Auto
Bus
Motorcycle
Tractor-Trailer
Truck
Section 5 of the NYS Tax Law requires the Department of Motor Vehicles to provide Social Security numbers to the NYS Department
Note:
of Taxation and Finance upon request.
NAME AND ADDRESS OF LICENSED DRIVING SCHOOL SUBMITTING THIS APPLICATION:
CHECK ONE
YOU MUST ANSWER ALL OF THE FOLLOWING QUESTIONS.
QUESTIONS ANSWERED “YES” MUST BE EXPLAINED BELOW OR ON ADDITIONAL PAGE(S).
YES NO
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o
1. Have you had one year or more of experience as an in-car driving school instructor? .................................................................
If yes, list the driving school(s) you worked for and how many hours of instruction you provided for each.
___________________________________________________________________________________
_____
Number of hours:
___________________________________________________________________________________
_____
Number of hours:
___________________________________________________________________________________
_____
Number of hours:
o
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2. Within the last three years, have you been convicted of any traffic tickets (but not parking tickets)?..........................................
3. Have you ever:
o
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a. been a Point & Insurance Reduction Program instructor? If yes, who did you teach for, and when did you teach?.................
o
o
b. been known by any name other than the one shown on this application? If yes, what name?...................................................
4. Are you presently involved with any charges or court proceedings relating to a DMV matter (including driving school,
o
o
Private Service Bureau, PIRP, and/or Vehicle Safety)?.................................................................................................................
NOTE: A suspension or revocation or a pending matter in violation of Vehicle and Traffic Law may be due cause for denial of this
application.
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MV-523 (3/17)
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