De-964e - Dps Parent Taught Driver Education Certificate Order Form printable pdf download

De-964e - Dps Parent Taught Driver Education Certificate Order Form

FOR DRIVER TRAINING STAFF USE ONLY - DPS Parent Taught Course Provider DE-964E

PT Course Provider Number:

Number of certs ordered:

Receipt #:

Prepared by:

Certificate numbers:

Fee paid:

Verified by:

Date paid:

Pick-Up or E-mail date/time:

Initialed:

DE-964E – DPS Parent Taught Driver Education Certificate Order Form

Parent Taught Course Name: _____________________________________________________ CP#

Certificates:

_________ X $2.00 each

Original Signature of Parent Taught Course Owner

Printed Name

Date

Check one box and enter the applicable address:

HARD COPIES (3-part paper completion certificates ready to issue)

Delivery Address:

Overnight Delivery of hard copies is not available. Out-of-state shipments are not available.

WALK-IN or PICK-UP service from 5701 Springdale Road, Austin, Texas will require 72 hours to process and a $25 service fee per

order - payable to Region XIII, ESC, DT. Call 512-505-0504 for details.

NUMBERS* (Identifying numbers for completion certificates printed and issued by the PT course provider)

* A certificate proof must be submitted and approved by the Driver Training Division before certificate numbers will be sold.

E-mail Address:

CREDIT CARD ORDERS

1. Go to

and place your order.

2. Fax this completed and signed order form to 512-919-5440.

MAIL-IN ORDERS

Certificates: _________ X $2.00 each

Total enclosed

$_________

Make check or money order payable to TEA-DPS. Cash is NOT accepted. Mail payment and this original completed and

signed order form to:

Texas Education Agency – DPS

P.O. BOX 13717

Austin, Texas 78711-3717

Orders will be processed only when fees and this signed order form have been received by the Driver Training office. No exceptions.

ESC 13

DE-964E (New 07/11/2012)

De-964e - Dps Parent Taught Driver Education Certificate Order Form