Dmv Form Di 505 PDF Details

Navigating the roadmap of driver safety and continuous education, one encounters the pivotal signpost of the DMV DI 505 form. This form, essential for anyone aspiring to become an instructor at a Driver Improvement Clinic, outlines the meticulous process and requirements needed to obtain an instructor's license. First introduced on August 10, 2012, its main purpose is clear: to streamline the certification of instructors dedicated to enhancing driver awareness and safety. Whether an applicant is stepping into the realm of driver improvement for the first time or is renewing their commitment and certification, a fixed application and yearly certification fee are mandatory steps. This form opens pathways for instructors aiming to cater to a wide range of audiences, from passenger to commercial drivers, and encompasses a versatile instructional scope including DMV-directed, court-directed, voluntary sessions, or those geared toward insurance company employees for heightened training and awareness. Moreover, it emphasizes the inclusivity of language options extending beyond English to Spanish and others, thus broadening the reach and impact of such educational endeavors. What sets this form apart is not just its detailed application process but also the intricate instructor agreement at its conclusion, which underscores a mutual commitment to uphold the standards and regulations set forth by the Department of Motor Vehicles. Through specifying conditions like conducting an eight-hour course, verifying student identification, and ensuring the successful completion of written exams, the DI 505 form serves as a cornerstone in bolstering road safety through educated driving practices.

QuestionAnswer
Form NameDmv Form Di 505
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdi505 curriculum vendor associated with the driver improvement clinic virginia form

Form Preview Example

DI 505 (08/10/2012)

Driver Improvement Clinic

INSTRUCTOR LICENSE APPLICATION

Purpose: Use this form to apply for a Driver Improvement Clinic instructor's license.

Instructions: Submit the completed application with the $50 yearly certification fee to the Commercial Licensing Work Center at the address above.

APPLICATION INFORMATION

Type of Application: (check one):

 

 

Original (first-time application)

 

 

Renewal

 

 

$50 - One Year Certification Fee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Instructor will provide instruction for:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Passenger Drivers

 

 

 

DMV-directed, court-directed, voluntary, insurance

 

 

Company employees - to provide training/awareness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commercial Drivers

 

 

 

DMV-directed, court-directed, voluntary, insurance

 

 

Company employees - to provide training/awareness

Instructor will provide instruction in:

 

 

 

English

 

Spanish

 

 

 

Other (specify______________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT INFORMATION

 

APPLICANT/INSTRUCTOR NAME (last)

(first)

(mi) (suffix)

TELEPHONE NUMBER

 

 

 

 

(

)

 

 

 

 

 

 

 

 

SSN OR DMV CUSTOMER NUMBER

 

 

EXPIRATION DATE (mm/dd/yyyy)

 

 

 

 

 

 

 

 

MAILING ADDRESS

 

CITY

STATE

 

ZIP CODE

 

 

 

 

 

 

PASSENGER VEHICLE COURSE CURRICULUM (Give vendor name and attach

INSTRUCTOR NUMBER

EXPIRATION DATE (mm/dd/yyyy)

 

copy of the certification)

 

 

 

 

 

 

 

 

 

 

COMMERCIAL VEHICLE COURSE CURRICULUM (Give vendor name and attach

INSTRUCTOR NUMBER

EXPIRATION DATE (mm/dd/yyyy)

 

copy of the certification)

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER IMPROVEMENT CLINIC INFORMATION

FULL NAME OF CLINIC (print or type)

FULL NAME OF OWNER(S)

BUSINESS OFFICE ADDRESS

 

CITY

 

 

STATE

ZIP CODE

 

 

 

 

E-MAIL ADDRESS

TELEPHONE NUMBER

FAX NUMBER

CELL PHONE NUMBER (if applicable)

 

(

)

(

)

(

)

 

 

 

 

 

 

 

INSTRUCTOR CERTIFICATION

I hereby make application for a driver improvement clinic instructor license and certify that all information contained in this application and on all supporting document(s) is true. By my signature I authorize the Department of Motor Vehicles to verify that my Virginia driver's record fulfills the requirements for my licensing under established criteria and statute. Instructor Agreement on the back of this form. By my signature, I also certify that I will comply with the conditions of the Driver Improvement Clinic.

I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.

INSTRUCTOR NAME (Print)

INSTRUCTOR SIGNATURE

DATE (mm/dd/yyyy)

DRIVER IMPROVEMENT CLINIC CERTIFICATION

I certify that the above named individual has applied to become an instructor or is an instructor, for this driver improvement clinic.

I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.

OWNER NAME (Print)

OWNER SIGNATURE

DATE (mm/dd/yyyy)

 

 

 

DMV USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

Clinic Code Number

Verification of:

Remarks:

 

Clerk Stamp

 

 

Fee

 

 

 

 

 

 

Instructor Certification(s)

Approved Date:

_______________

 

 

 

 

Driver Record Verified:

Expiration Date: ________________

 

 

 

 

 

 

 

 

Demerit Points:____________

Denied

 

 

 

 

 

 

 

 

 

 

 

Date Checked: ____________

 

 

 

 

 

 

 

 

 

 

 

DI 505 (08/10/2012)

Driver Improvement Clinic

Instructor Agreement

The Department of Motor Vehicles (hereafter referred to as "DMV") and __________________________________________________________ (hereafter

referred to as Instructor), mutually agree to the following:

To apply, Instructor must:

1.Submit a completed application.

2.Pay the DMV license fee.

3.Hold a valid driver's license that reflects no more than 6 demerit points. If the driver's license is out-of-state, a copy of the valid driver's license must be provided to DMV.

4.Hold a valid instructor certification with a DMV-approved curriculum vendor associated with the driver improvement clinic at the time of licensing and throughout the licensure period. The expiration of the instructor's certification shall coincide with the expiration of the respective clinic certification. No instructor will be permitted to continue instructing students upon the expiration of the instructor's certification with the curriculum vendor or DMV

Instructor Requirements for Class Instruction:

1.Verify each student's identification using a picture identification issued by a government agency.

2.Follow the curriculum and properly utilize the training materials provided by a DMV-approved curriculum vendor.

3.Conduct a full eight-hour course of classroom instruction, including administration of the final written exam. Meals and other breaks will not count towards the eight-hour requirement.

4.Permit students to take the final written exam only once each calendar day.

5.Final written exams shall consist of subject matter questions.

6.Students must answer at least 80% of the questions correctly to successfully complete the course. Issue the appropriate Certificate of Completion to each student successfully completing the course.

7.Report clinic attendance to clinic owner within 24 hours of clinic completion.

Notification of Change Requirements:

1.Instructor must provide written notice to DMV within thirty working days if there are changes that will affect the instructor's record with DMV.

Additional Limitations:

1.Instructor cannot use the DMV logo on any form of advertising.

2.School advertisements cannot be placed in the DMV customer service centers.

CERTIFICATION AND SIGNATURES

By signing this document, I agree to the terms and the conditions specified above. This agreement shall become effective upon signing and shall be renewed on an annual basis. Either party may terminate this Agreement by giving written notice within 30 working days of the termination. I understand that failure to comply with any of the terms of this agreement may result in suspension or termination of the clinic's or instructor's certification, and assessment of civil penalty.

I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation

INSTRUCTOR NAME (Print)

INSTRUCTOR SIGNATURE

DATE (mm/dd/yyyy)

FOR DMV USE ONLY

AGREEMENT EFFECTIVE DATE

AGREEMENT EXPIRATION DATE

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This form will need specific details; in order to ensure correctness, make sure you take into account the recommendations down below:

1. While completing the Dmv Form Di 505, ensure to incorporate all of the important blank fields in its associated section. This will help to facilitate the process, enabling your information to be handled fast and accurately.

Dmv Form Di 505 completion process clarified (step 1)

2. When the previous part is complete, it's time to insert the necessary particulars in BUSINESS OFFICE ADDRESS, CITY, STATE, ZIP CODE, EMAIL ADDRESS, TELEPHONE NUMBER, FAX NUMBER, CELL PHONE NUMBER if applicable, INSTRUCTOR CERTIFICATION, I hereby make application for a, I further certify and affirm that, INSTRUCTOR NAME Print, INSTRUCTOR SIGNATURE, DATE mmddyyyy, and DRIVER IMPROVEMENT CLINIC so that you can proceed further.

STATE, INSTRUCTOR CERTIFICATION, and I hereby make application for a inside Dmv Form Di 505

People frequently make errors when filling in STATE in this area. Be certain to reread everything you type in right here.

3. This next step is normally hassle-free - fill out all the fields in The Department of Motor Vehicles, To apply Instructor must Submit a, at the time of licensing and, Instructor Requirements for Class, other breaks will not count, Permit students to take the final, Certificate of Completion to each, and Report clinic attendance to in order to complete this part.

The best way to prepare Dmv Form Di 505 portion 3

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