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STATE OF GEORGIA
DEPARTMENT OF DRIVER SERVICES
REGULATORY COMPLIANCE DIVISION
2206 EAST VIEW PARKWAY – P.O. BOX 80447
CONYERS, GA 30013
APPLICATION FOR RISK REDUCTION INSTRUCTOR CERTIFICATION
(last, first, middle)
2. Resident Address:
(street, city, county, zip)
Mailing Address (if different):
3. Telephone Number:
4. Date of Birth:
5. Social Security #:
7. Name of Spouse:
8. Spouse’s Occupation:
9. Are you presently the owner or director of a Risk Reduction Program? Yes
IF YES, NAME/LOCATION OF PROGRAM:
10. Have you made plans to be an instructor for any particular Program? Yes
IF YES, WHICH PROGRAM?
11. Are you a legal resident of the U.S.?
(If not a resident, attach proof of legal residency)
12. Do you have a current Georgia Driver’s License? Yes No
IF YES, INDICATE NUMBER OF YEARS LICENSED IN GEORGIA
Georgia Driver’s License Number:
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13. Have you ever been licensed in another state? Yes No
IF YES, WHAT STATE?
14. Have you had a driver’s license revoked, suspended, cancelled or denied in Georgia, or in any other State in
the last 3 years? Yes No
IF YES, WHEN?
15. Have you ever been arrested for any reason?