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APPLICATION FOR NEW SCHOOL BUS DRIVER INSTRUCTOR STATE OF CONNECTICUT DEPARTMENT OF MOTOR VEHICLES R-359 Rev. 5-2012 DRIVER EDUCATION UNIT Instructions to Applicant: PLEASE PRINT OR TYPE. Answer all questions completely and truthfully. Completed form must be signed by employer and by a DMV approved instructor. Full name of applicant (Last, First, MI) Employer Home Address Address City, State, Zip City, State, Zip Daytime Phone E-mail Phone Date of Birth: Connecticut Operator's License Number: Classifications and Public Transportation Endorsements: (Circle all applicable) Fax Class: A B Endorsements: Restrictions: C A L D V K S B P M Place of Birth: (City & State) F Number of Years Licensed: N High School Education: (School Name and year of Graduation) Number of Years School Bus Driver: Have you ever been refused a driver's license by any state? If so, explain. Has your license or registration ever been revoked or suspended in any state? If so, explain. Have you ever been convicted or fined for a motor vehicle violation other than parking? (if yes, give dates and offenses). Have you ever been convicted of a crime? Give dates and offenses. How long have you been training school bus drivers under the direct supervision of an approved instructor? Instructor's Name(s) & ID Number(s) Certification: I certify under penalty of false statement (per CGS §14-110 ref. 53a-157) that the above information is true and accurate on the date of this application. Applicant's Signature Date I recommend this applicant for approval as a school bus driver instructor. He/she is employed by me and is a proficient driver with good communication skills. Upon successful completion of training, the applicant will be utilized as a school bus or STV driver instructor. Certified Instructor's Signature Date Employer's Safety Coordinator's Signature Date Send Completed and Signed Applications to: DMV - Driver Education Unit, 60 State Street, Room 305, Wethersfield, CT 06161 FOR DMV USE ONLY Approval granted Date Signed