Form Mv-278.6 - Authorized Signature List
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1AUTHORIZED SIGNATURE LIST
Pre-Licensing Course
INSTRUCTIONS: You must complete and submit this form if your driving school teaches the Pre-Licensing Course when you file
an original Driving School License Application (form MV-521), Driving School Renewal Application (form MV-522), and/or if you
want to change the name of any person who signs certificates or orders books of Pre-Licensing Course Completion Certificates
(form MV-278).
NOTE:
Only classrooom-endorsed instructors who teach a pre-licensing course may issue a completion certificate (form MV-278).
l
Only the owner or authorized classroom-endorsed instructor may sign a duplicate Pre-Licensing
l
Course Completion Certificate (form MV-278).
Print name and address of
your driving school here:
LIST ALL INDIVIDUALS WHO ARE AUTHORIZED TO:
P
/purchase books of Pre-Licensing Course Completion Certificates (form MV-278) for your driving school.
Request
P
the Pre-Licensing Course for your driving school.
Teach
P
duplicate Pre-Licensing Course Completion Certificates (form MV-278).
Sign
Put a check ( 4 ) below to show what each is authorized to do:
Print Name
Request
Teach the Pre-
Sign Duplicate
MV-278 Books
Licensing Course
Certificate(s)
Signature
Title
ç
Print Name
Request
Teach the Pre-
Sign Duplicate
MV-278 Books
Licensing Course
Certificate(s)
Signature
Title
ç
Print Name
Teach the Pre-
Sign Duplicate
Request
MV-278 Books
Licensing Course
Certificate(s)
Signature
Title
ç
Print Name
Request
Teach the Pre-
Sign Duplicate
MV-278 Books
Licensing Course
Certificate(s)
Signature
Title
ç
Print Name
Request
Teach the Pre-
Sign Duplicate
MV-278 Books
Licensing Course
Certificate(s)
Signature
Title
ç
(Title)
(Print Name)
ç
(Date)
(Signature of Authorized Official)
Send completed
NYS Department of Motor Vehicles
FOR OFFICE USE
Bureau of Driver Training Programs, Certification & Oversight
form to:
Request approved by ___________________________________
6 Empire State Plaza, Room 221
Albany NY 12228
Office __________________________ Date_________________
MV-278.6 (2/16)
RESET/CLEAR
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Parent category: Legal