Form Mv-285r - Student Mv-285 Poster

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STUDENT MV-285 ROSTER
(Please Print or Type)
Name of School
Contact Person
Dates course was offered:
Date certificates were issued:
From:
/
/
To:
/
/
/
/
Address (Number and Street)
City
State
Zip Code
Telephone Number (include area code)
Signature of Superintendent or Principal
ç
(
)
Numerical Grade
Duplicate
Laboratory Hours
Last Name, First Name, Middle Initial and
Received
Class
Total
Certificate No.
Student’s Client
Certificate No.
Date of Birth
Address of Student
Behind the
Behind the
and Date Issued
Hours
Hours
ID Number
Wheel
Observation
Simulation
Range
Wheel
Classroom
To knowingly make a false statement or conceal a material fact in this Student MV-285 Roster is a criminal offense.
Mail completed roster to: NYS Department of Motor Vehicles
Utica Processing Center
False statements are punishable under Section 210.45 of the Penal Code.
MV-285/MV-278
ç
207 Genesee Street
/
/
_______________________________________________ ______________________________ ____________________
Utica, NY 13501
Signature of Approved MV-283 Lecture Teacher
Instructor Certificate Number
Date
Telephone (315) 793-2615
(If multiple Lecture Teachers are employed, only Lead Teacher Signs)
MV-285R (1/16)

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