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GEORGIA DEPARTMENT OF DRIVER SERVICES Instructions for Driver Training Instructor’s License Application First Time Applicants: The items listed below must be submitted with the application. Incomplete applications will be rejected. 1. Complete, in entirety, the application and all attachments. A Notary Public must notarize this application. 2. Include one (1) color, 2” x 2” photograph showing a full view of the face, neck, shoulders, and uncovered head, taken within thirty (30) days of filing application. Photo must be 2” x 2” and will be used on the instructor license. 3. Fingerprint Cards or Background: Please see the next page for detailed instructions. 4. Attach a laboratory report, from an accredited lab, which shows the results of a minimum five-panel drug screen. (The lab report cannot be more than 30 days prior to application date.) 5. Attach the Physical Examination Report completed and signed by your doctor. (The Physical Examination Report cannot be more than 30 days prior to the application date.) Physical must also be signed by applicant. 6. If you have been licensed in a state (or states) other than Georgia in the past five (5) years, you must obtain a Motor Vehicle Report (MVR) from each state and submit with application. 7. A notarized statement from the owner of the school, or high school principal; stating that the applicant is or will be employed by the school. This step may be omitted if applicant is the owner of the school. 8. Complete the Consent for Background Investigation Form and have notarized. 9. Include an application fee of $5.00, in the form of a money order, certified check, or cashier’s check and made payable to Georgia Department of Driver Services. 10. Examination fee of $25.00, in the form of a money order, certified check, or cashier’s check and made payable to the Georgia Department of Driver Services. Neither fee nor examination are required if applicant submits a valid Georgia teaching certificate reflecting certification in Safety and Driver Education. You will be notified of training dates and locations after your application has been accepted. Training is offered at DDS Headquarters in Conyers twice a month. Additional classes are offered as needed. Reservations for training classes are required. Renewal Applications: The items listed below must be submitted with the application. Incomplete applications will be rejected. 1. Complete, in entirety, the application and all attachments. A Notary Public must notarize this application. 2. Include one (1) color, 2” x 2” photograph showing a full view of the face, neck, shoulders, and uncovered head, taken within thirty (30) days of filing application. Photo must be 2” x 2” and will be used on the instructor license. 3. Attach a laboratory report, from an accredited lab, which shows the results of a minimum five-panel drug screen. (The lab report cannot be more than 30 days prior to application date.) 4. Attach the Physical Examination Report completed and signed by your doctor. (The Physical Examination Report cannot be more than 30 days prior to the application date.) Physical must also be signed by applicant. 5. A notarized statement from the owner of the school, or high school principal, that the applicant is or will be employed by the school named on the application. 6. Complete the Consent for Background Investigation Form and have notarized. 7. Include an application fee of $5.00, in the form of a money order, certified check, or cashier’s check and made payable to Georgia Department of Driver Services. Additional or Transfer Applications: The items listed below must be submitted with the application. Incomplete applications will be rejected. 1. Complete, in entirety, the application and all attachments. A Notary Public must notarize this application. 2. Include one (1) color, 2” x 2” photograph showing a full view of the face, neck, shoulders, and uncovered head, taken within thirty (30) days of filing application. Photo must be 2” x 2” and will be used on the instructor license. 3. If transferring, attach old instructor’s license to this application. 4. Include an application fee of $5.00, in the form of a money order, certified check, or cashier’s check and made payable to Georgia Department of Driver Services. 5. A notarized statement from the owner of the school, or high school principal, that the applicant is or will be employed by the school named on the application. 6. Complete the Consent for Background Investigation Form and have notarized. 7. Option 1: To have the license issued for four (4) years, include the following two attachments: a. Attach a laboratory report, from an accredited lab, which shows the results of a minimum five-panel drug screen. (The lab report cannot be more than 30 days prior to application date.) b. Attach the Physical Examination Report completed and signed by your doctor. (The Physical Examination Report cannot be more than 30 days prior to the application date.) Physical must also be signed by applicant. Option 2: If you do not include the Physical Examination Report or results of a drug screen, the additional or transfer instructor license will expire on the same date as your initial instructor license. Please mail applications to: DDS, Regulatory Compliance Division, P.O. Box 80447, Conyers, GA 30013 2 THREE OPTIONS TO COMPLETE BACKGROUND REQUIREMENTS Applicants seeking to be licensed by the Regulatory Compliance Division are required to be fingerprinted for a background investigation. Unless otherwise requested, applicants renewing school or instructor licenses are not required to be fingerprinted. Option 1: Applicant Fingerprint Cards: applicants are required to be fingerprinted by a law enforcement agency. Applicants should submit the following with their application: • Two (2) fingerprint cards • $26.00 fee** in certified funds (money order or cashier check), made payable to the G.B.I. • Affidavit signed by the fingerprinting officer Our department submits the fingerprint cards to the Georgia Crime Information Center (GCIC) for manual processing. Processing takes between 90 to 120 days. If fingerprint cards are rejected due to poor print quality, or any other reason, the applicant will be required to be re-fingerprinted and may be required to submit additional fees to cover fingerprint processing cost. Option 2: Live Scan Automated Fingerprinted conducted by DDS at the Conyers Headquarters: Fingerprinting is conducted on Mondays from 9:00 am to 3:00 pm. Cost is $49.00. Only applicants that have submitted an application, paid the $49.00 fee and have been notified by our department will be fingerprinted. Do not show up for fingerprinting until you have been notified that your application has been accepted. Background reports are usually completed within a few days of fingerprinting. Applicants wishing to be fingerprinted by DDS should submit the following with their application: • $49.00 fee in certified funds (money order or cashier check), made payable to DDS • Complete Background Fact Sheet (part of application) Option 3: Live Scan Automated Fingerprinting by other Law Enforcement Agencies: Check with your local law enforcement agencies to determine if they have the capability to conduct automated fingerprinting. Applicants will need to request a printout showing the background results from the G.B.I. and the F.B.I. Reports showing only G.B.I. results or “no arrests” will not be accepted. Background reports contain personal information; please do not fax a copy to our office. Important Note: If the fingerprinting official enters the Georgia Department of Driver Services’ ORI Number into the system, the applicant will receive a bill from our department to cover fingerprint process charges. The applicant, or their employer, will be required to pay the charges even if payment was submitted at the time of fingerprinting. Applicants should submit the following with their application: • Background report printouts • Affidavit signed by the fingerprinting officer All background reports are subject to review by the DDS Legal Division. Applicants may be required to submit copies of depositions, pardons or other legal documents. **Effective October 1, 2007: The Fingerprint fee increased from $24.00 to $26.00 3 LIVE SCAN AUTOMATED FINGERPRINTING & APPLICANT FINGERPRINT CARDS A F F I D A V I T To be completed by the Official taking fingerprints. Affidavit must be signed and dated. STATE OF GEORGIA COUNTY OF _________________________ I do solemnly swear (or affirm) that the attached fingerprints are those of the applicant named herein: ____________________________________________________________________________ __________________________________ Signature of Official Taking Fingerprints __________________________________ Name of Above Official’s Agency __________________________________ Date of Fingerprinting Live Scan Automated Fingerprinting: The applicant will need to be given a printout showing the background results from the G.B.I. and the F.B.I. If the Georgia Department of Driver Services’ ORI Number is entered into the system, the applicant will receive a bill from our department to cover fingerprint processing charges. The applicant will be required to pay the charges. Applicant Fingerprint Cards: If fingerprint cards are submitted to the Georgia Department of Driver Services, a $26.00 fee, made payable to the G.B.I., is required. BEFORE SENDING IN THE FINGERPRINT CARDS, BE SURE TO FILL IN THE FOLLOWING ON THE FINGERPRINT CARDS: Residence Height Place of Birth Weight Nationality Color of Hair Age Color of Eyes Date of Birth Social Security Number Race Citizenship The fingerprint cards without the forgoing information will not be accepted. **This form is not required if applicants are to be fingerprinted by DDS at Conyers Headquarters** 4 The DDS Headquarters office in Conyers has the capability to conduct automated fingerprinting. Background reports are usually completed within days instead of months. Complete the information below and submit a money order or cashier’s check for $49.00. Fingerprinting is conducted on Mondays from 9:00 am to 3:00 pm. Only applicants that have submitted an application, paid the $49.00 fee and have been notified by our department will be fingerprinted. DO NOT SHOW UP FOR FINGERPRINTING UNTIL YOU HAVE BEEN NOTIFIED THAT YOUR APPLICATION HAS BEEN ACCEPTED. BACKGROUND FACT SHEET DATE: ____________________________ NAME:_________________________________________________________________ ALIAS:________________________________________________________________ ADDRESS: ______________________________________________________________ DATE OF BIRTH: ________________ SOCIAL SECURITY #: _____________________ SEX:_____ RACE:_______ HGT:_______ WGT:______ EYES:_______ HAIR:_______ PLACE OF BIRTH: ________________________________________________________ CITIZENSHIP: __________________________________________________________ EMPLOYER AND ADDRESS: _________________________________________________ __________________________________________________________________________ **To be completed by applicants seeking to be fingerprinted by DDS at Conyers Headquarters** 5 IMPORTANT NOTICE TO INSTRUCTORS Background Investigation: The G.B.I., F.B.I, and a DDS Investigator will conduct a full and complete background investigation before any instructor’s license is issued. No license will be issued to any applicant who has been convicted of: any felony, violence, dishonesty, deceit, fraud, indecency or moral turpitude. If you have been arrested for any of the above, but not convicted, you will be asked to submit a copy of the disposition from the courts. If you have received a pardon you will need to provide evidence of the pardon. Driving History: Your driving history will also be verified before an instructor’s license is issued. No instructor’s license will be issued if: Your driver’s license was suspended for any reason within one (1) year of making application. Your driver’s license was suspended for two (2) or more times within five (5) years of making application. You have plead guilty, had a bond forfeiture, or a nolo contendere for any mandatory suspension offense (see below) within one (1) year prior to making application. You have plead guilty, had a bond forfeiture, or a nolo contendere to two (2) or more mandatory suspension offenses (see below) with five years prior to making application. Drivers License Mandatory Suspension Offenses (If Convicted) Homicide by vehicle. A conviction for driving under the influence of alcohol or drugs. Any felony in the commission of which a motor vehicle is used. Using a motor vehicle in fleeing or attempting to elude an officer. Fraudulent or fictitious use of, or application for a license. Hit and run or leaving the scene of an accident. Racing. Failure to maintain liability insurance coverage (No Fault). Refusal to take a chemical test for intoxication, then your license will be suspended for 12 months. Failure to maintain minimum liability coverage of any automobile, which you may own or operate. Conviction for driving without insurance is a 60/90-day suspension. If convicted for driving while license is suspended, revoked or canceled, your driver license will be further suspended for six months. Failure to appear in court or respond to a citation. Possession, distribution, manufacture, cultivation, sale or transfer of a controlled substance or marijuana. Accumulation of 15 points within 24 months under the point system, including violations committed out-of- state. Instructor Training: Before an instructor’s license can be issued you will be required to attend a four (4) hour training class and successfully pass an examination administered by this Department. The study guide for the examination is the Georgia Drivers Manual, which can be obtained from any DDS Customer Service Center and is also available at www.dds.ga.gov The training class will cover the Rules and Regulations for Driver Training Schools and Instructors, the Teenage & Adult Driver Responsibility Act (TADRA), Joshua’s Law requirements, and Driver License issuance requirements and skill testing. You will be notified of training dates and locations after your application has been accepted. Training is offered at DDS Headquarters in Conyers twice a month. Additional classes are offered as needed. Reservations for training classes are required. 6 Georgia Department of Driver Services 2206 East View Parkway • P.O. Box 80447 • Conyers, GA 30013 Driver Training Instructor Application Check the Type of Application: First-Time Applicant Renewal Transfer Additional Applicant’s Information: Please type or print clearly Applicant’s Full Name: ____________________________________________________________________ (Last) (First) (Middle) Residence Address: ______________________________________________________________________ (Street) (City) (State) (Zip) Mailing Address: _________________________________________________________________________ (Street) (City) (State) (Zip) Home Telephone #: (_____)_______________________ Work or Cellular: (_____)____________________ E-Mail Address: _________________________________Date of Birth: _____________________________ Height: __________ Weight: ____________ Color of Hair: _______________ Color of Eyes: ____________ School Information (Instructors must be employed by an approved driver training school; for a list of approved schools please visit www.dds.ga.gov) Employed by (DDS approved driver training school): ___________________________________________ Address of school: _______________________________________________________________________ List name of school transferring from (if applicable): __________________________________________ List all schools previously employed by: ______________________________________________________ Type of instruction you will giving to students: Both Classroom and Behind the Wheel Instruction Classroom instruction only Behind the Wheel Instruction only Driving and License History Do you possess a current Georgia Driver’s License? Yes No. Driver’s License #: _____________________________ Number of years licensed in Georgia: _____________ Have you ever been licensed in any other state? Yes No. If yes, what state? _____________________ For how long were licensed in that state: ____________ 7 Driving and License History Continued Have you ever have a Driver’s license revoked, suspended, cancelled, or denied in Georgia or any other state? Yes No. If so, when and where? ______________________________________________________________ Provide date for each occurrence: ______________________________________________________ Have you been re-licensed since that time? Yes No. If so, give date of re-licensing: __________________________________________________________ Have you ever been convicted of a traffic violation? Yes No. If so, when? _______________________ What offense? ______________________________________________________________________ Location of offense? ____________________________________ More than once? Yes No. Have you ever been involved as a driver in an automobile accident? Yes No. If yes, give date of accident: _________________________ Any fatalities? Yes No. Any Injuries? Yes No. Location of accident: _______________________________________ Have you ever been convicted of fraud or fraudulent practices in relation to securing a license to drive a motor vehicle? Yes No. If yes, give particulars: _________________________________________________ Background Information Have you plead guilty, entered a plea of nolo contendere, or been found guilty of any crime by a judge or jury in any state or federal court? Yes No. What were the charge(s)? _______________________________________________________________ When: ____________________________ Where: ___________________________________________ Are there any proceedings pending against you relative to any crime, misdemeanors, or violations? Yes No. If so, give particulars: _________________________________________________________ Have you ever been addicted to narcotic drugs or intoxicating liquor? Yes No. If so, are you in total abstinence? Yes No. How long have you been drug free? ___________ Have you ever been a patient in or committed to an institution for the treatment of alcohol or drug addiction? Yes No. If so, date(s)? _______________________________________________________________ Name and location of institute: ___________________________________________________________ 8 Background Information Continued Give date of release or last treatment: ______________________________________________________ Do you have a relative employed by the Georgia Department of Driver Services? Yes No. If yes, give name __________________________________________ Position: ____________________ Relationship: _________________________________________________________________________ Educational Record School Name and Location Years Attended Credits or Diplomas High School College Vocational School Other Work History List all teaching or instructional experience: _____________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Under penalty for perjury, I do hereby swear or affirm that the information contained within this application, and any statements made in connection therewith, are complete, true and correct. _______________________________________________ Signature of Applicant Date Sworn to before me this _________________ day of ___________________________, ___________ _________________________________________________________________________________ Notary Public Seal Required _________________________________________________________________________________ Commission Expires TO KNOWINGLY MAKE A FALSE STATEMENT OR CONCEAL A MATERIAL FACT IN THIS APPLICATION WILL RESULT IN THE CANCELLATION OF YOUR CERTIFICATE OF APPROVAL 9 CONSENT FOR BACKGROUND INVESTIGATION I hereby apply for a Certificate (to operate a Driver Training School and/or Driver Improvement School and/or to become an Instructor) to be issued by the Department of Driver Services (DDS). I understand that my criminal history and driver’s history will be checked, and hereby give consent for the DDS to conduct whatever investigations necessary to determine my eligibility to hold such a certificate. I understand that false, misleading, or incomplete information may result in certificate denial, cancellation, suspension, or revocation, and possible criminal and civil prosecution. Under penalty for perjury, I do hereby swear or affirm that the information contained within this application, and any statements made in connection therewith, are complete, true and correct. THIS CONSENT FORM MUST BE NOTARIZED Signature Date Subscribed to and sworn before me: Notary Signature Date My commission expires: ___________________________ SEAL OR STAMP OFFICE USE ONLY FILE NUMBER: OFICE USE ONLY OFFICE USE ONLY DATE APPLICATION RECEIVED: OFFICE USE ONLY BACKGROUND DRIVER’S HIST P F CRIMINAL HIST P F OFFICE USE ONLY Department of Driver Services 2206 East View Parkway, P.O. Box 80447, Conyers, GA 30013 Last Name First Name Middle Date of Birth (MM/DD/YYYY) / / Driver’s License Number (Include ALL zeros) Issue date (Exam date) State (GA License Required) Social Security Number Georgia Current Street Address City and State Zip Code Do you hold any other driver’s license(s)? If so, list state(s) and license number(s) Phone Number Yes No Company Phone Number Address City and State Zip Code Have you been convicted, plead guilty to, plead nolo contendere to, served time, or been on probation or parole for any crime whether felony or misdemeanor, in this state, any other state, or of the federal system? Yes No Do you have a charge or court hearing pending or are you under any indictment? Yes No If you are now charged, under indictment, or have court hearings pending for any charges, give details below: 10 Return form to the Regulatory Compliance Division PHYSICAL EXAMINATION CERTIFICATE A copy of the official Laboratory Report for a Drug Screening must be attached to this Physical Examination Certificate. Drug Screen should include, as a minimum: Amphetamines, Cocaine Metabolites, Marijuana Metabolites, Opiates, and Phencyclidine. Physical and Drug Screen must be administered within thirty (30) days of filing application. Name: (First) (Middle) (Last) Address: (Street) (City) (State) (Zip Code) Date of Birth: (Month) (Day) (Year) Health History Yes No Yes No Any illness or injury in last 5 years Eye disorders or impaired vision (except corrective lenses) Head/Brain injuries, disorders or illnesses Ear disorders, loss of hearing or balance Seizures, epilepsy Medication ________________ Heart disease or heart attack; other cardiovascular condition Medication______________________ High blood pressure Medication _________________ Heart surgery (valve replacement/bypass, angioplasty, pacemaker) Muscular disease Fainting, dizziness Shortness of breath Stroke or paralysis Lung disease, emphysema, asthma, chronic bronchitis Spinal injury or disease Kidney disease, dialysis Chronic low back pain Liver disease Regular, frequent alcohol use Diabetes or elevated blood sugar controlled by: Diet Pills Insulin Nervous or psychiatric disorders e.g., severe depression Medication ____________________________ Other illness or injuries: Physical Information General appearance and development: Good Fair Poor Height: Weight: Eyes for Distance (without glasses/contacts): Right 20 / Left 20 / Eyes for Distance (with glasses/contacts): Right 20 / Left 20 / Evidence of injury: Right: Left: Color Vision: Horizontal Field: Right: Left: Ears (Hearing @ 20 ft.): Right: Left: 11 Yes No Body System: Check For: General Appearance Marked overweight, tremor, signs of alcoholism, problem drinking, or drug abuse. Eyes Papillary equality, reaction to light, accommodation, ocular motility, ocular muscle imbalance, extraocular movement, nystagmus, exophthalmos, strabismus uncorrected by corrective lenses, retinopathy, cataracts, aphakia, glaucoma, macular degeneration. Ears Middle ear disease, occlusion of external canal, perforated eardrums. Mouth and Throat Irremediable deformities likely to interfere with breathing or swallowing Heart Murmurs, extra sounds, enlarged heart, pacemaker. Lungs and chest, not breast examination Abnormal chest wall expansion, abnormal respiratory rate, abnormal breath sounds including wheezes or alveolar rales, impaired respiratory function, dyspnea, cyanosis. Abnormal finding on physical exam may require further testing such as pulmonary tests and/or x-ray of chest. Abdomen and Viscera Enlarged liver, enlarged spleen, masses, brutis, hernia, significant abdominal wall muscle weakness. Vascular System Abnormal pulse and amplitude, carotid or arterial bruits, varicose veins. Genito-urinary system Hernias. Spine, other musculoskeletal Previous surgery, deformities, limitation of motion, tenderness. Neurological Impaired equilibrium, coordination or speech pattern; paresthesia, asymmetric deep tendon reflexes, sensory or positional abnormalities, abnormal patellar and Babinski’s reflexes, ataxia. Extremities – Limb Impaired Loss or impairment of leg, foot, toe, arm, hand, finger. Perceptible limp deformities, atrophy, weakness, paralysis, clubbing, edema, hypotonia. Insufficient grasp and prehension in upper limb to maintain steering wheel grip. Insufficient mobility and strength in lower limb to operate pedals properly. Comments: Laboratory Findings: Urine: Spec. Gr.: Protein Sugar: Blood Pressure (Sitting): Systolic: Diastolic: Pulse: Before Exercise: Two Minutes After Exercise: Instructor’s Certification: I certify that I have answered all medical questions honestly and to the best of my knowledge. ___________________________________________________________ _________________ Signature of Driver Trainer Instructor Date Doctor’s Certificate This is to certify that I have this Day of , 20 examined and that I find his/her physical condition is sufficiently sound to perform the duties required by a Driver Training Instructor. Street Address of Examining Doctor ______________________________________________________ Printed Name of Examining Doctor ______________________________________________________ Signature of Examining Doctor City State Zip
