Dl 396 Form – Fill Out and Use This PDF

A Public Service Agency	AUTHORIZATION/REQUISITION FOR
	DRIVER INSTRUCTION FORMS

Send the original copy to:

Occupational Licensing Section

P. O. Box 932342, MS L224,

Sacramento, CA 94232-3420

INSTRUCTIONS: Complete appropriate sections. Please print in ink or type. Retain a copy for your iles.

Check one:
Public Secondary School	Private Secondary School		Home School or Private School Satellite Program
SECTION 1: REQUESTER INFORMATION
NAME Of SCHOOL		CDS CODE (If ISSuED)		SCHOOL I.D. NuMBER (If ISSuED)
NAME Of REquEStER (OwNER/OffICE/ADMINIStRAtOR/PRINCIPAL)		REquEStER’S PHONE NuMBER		DAtE Of REquESt
		(	)
SCHOOL’S MAILINg ADDRESS (CHECK BOX IF NEW MAILING ADDRESS)		CIty		StAtE	ZIP CODE
SCHOOL’S DELIVERy ADDRESS (IF DIFFERENT) (CHECK BOX IF NEW DELIVERY ADDRESS)		CIty		StAtE	ZIP CODE

Do not use P.o. box foR DeliveRy aDDRess

these forms/certiicates can be received between		and		, from		A.M.to		P.M.
	MM/DD		MM/DD

SECTION 2: TO BE COMPLETED BY ALL REQUESTERS. CheCk all boxes that aPPly

this is a public or charter secondary school teaching at the high school level authorized by the Department of Education.

this school offers driver education and/or behind-the-wheel training as part of the full time curriculum to full time students enrolled in this school, pursuant to California Education Code §§51850, 51851.

the driver education/behind-the-wheel training courses offered by the same school must be maintained pursuant to California Education Code §§51220(j), 51220.1, 51220.4, 51850, 51851, 51852.

SECTION 3: TO BE COMPLETED BY ALL PRIVATE SCHOOLS, HOME SCHOOLS AND PRIVATE SCHOOL SATELLITE PROGRAMS (PSSP). CheCk all boxes that aPPly.

this is a private secondary school that complies with California Education Code §§33190 and 33191.

Enclosed is a current copy of the “Private School Affidavit” (PSA) iled with the Superintendent of Public Instruction as required by California Education Code §33190.

this is a private secondary school that teaches classroom driver education in compliance with California Education Code §§51220(j), 51220.1, 51220.4.

this is a home school or private school satellite program that teaches classroom driver education.

this is a home school or private school satellite program that teaches behind-the-wheel training.

this is a private secondary school or PSSP that teaches non-classroom driver education instruction including but not limited to, Internet-based, correspondence, or other distance-learning courses, in compliance with California Education Code § 51220.6(c). Please check the appropriate box for the type of driver education curriculum used.

Department of Motor Vehicle’s driver education curriculum under subdivision (f) of former §12814.8 of the California Vehicle Code.

Driver education curriculum is educationally equivalent to the Department of Motor Vehicles. Please complete the Private Secondary School Non-Classroom Driver Education Curriculum Certiication form (DL 396 B) and return with the request for certiicates of completion.

DL 396 (REV. 4/2010) WWW

SECTION 4: SECONDARY SCHOOL AGE STUDENTS

Provide the number of secondary school age students to be enrolled in Driver education/behind-the-Wheel training for the current school year (september through august, including summer session). note: the total number of students must not exceed the total number of secondary school age students reported on the school’s Psa.

DRIVER EDUCATION ONLY DRIVER EDUCATION ONLY		BEHIND-THE-WHEEL	TOTAL NUMBER OF
(CLASSROOM)	(NON-CLASSROOM)	ONLY	STUDENTS

ENROLLMENT

SECTION 5: DRIVER EDUCATION/BEHIND-THE-WHEEL INSTRUCTORS

Provide the names of the Driver education/behind-the-Wheel training instructors employed by a secondary school. also provide the names of Driver education/behind-the-Wheel training instructors of the home school or PssP. attach additional sheet(s) if necessary.

An instructor is an employee that performs a service for another, expressed or implied, oral or written, where the employer has the power or right to control and direct the employee in the material details of how the work is to be performed. If the instructor does not possess a current California teaching credential, the employer must submit two sets of ingerprints of the instructor to Department of Justice for the purpose of obtaining criminal record summary information.

for private schools “employment” means the act of engaging the services of a person, who will have contact with pupils, to work in a position at a private school at the elementary or high school level on or after September 30, 1997, on a regular paid full-time basis, regular paid part-time basis or paid full- or part- time seasonal basis pursuant to California Education Code §44327(b)(2).

NOTE: A parent or guardian instructing only their child is exempt from the criminal record summary requirement.

		INSTRUCTOR		CheCk one
	PRINT NAME	SIGNATURE	PARENT OR	TEACHING	CRIMINAL RECORD
			GUARDIAN	CREDENTIAL	SUMMARY

X

X

X

X

X

X

X

X

X

X

X

X

SECTION 6: CERTIFICATION

The signatory must be the owner, officer, administrator or principal of the school. An instructor, secretary or representative is not an authorized signatory.

i certify (or declare) under penalty of perjury under the laws of the state of California that the foregoing is true and correct.

DL 396 (REV. 4/2010) WWW