Commonwealth of the Northern Mariana IslandsDepartment of Public Safety

Driver Education Instructor Application

Required Document Signature Date of Approval

Completed Application

Fee - $100

Fingerprint Affidavit

Police Clearance

Traffic Clearance

NSC Defensive Driving Certificate

Praxis II Exam Scores

CPR Certificaion

High School Diploma/GED

Others (Teaching Credentials

Certificate Issued

COMMONWEALTH REGISTER VOLUME 30 NUMBER 04 April 25, 2008

April 2008 Bureau of Motor VehiclesDriver Education Instructor Application

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DEPARTMENT OFPUBLIC SAFETY

Commonwealth of the Northern Mariana IslandsBureau of Motor Vehicles

Driver Education Instructor Application

COMMONWEALTH REGISTER VOLUME 30 NUMBER 04 April 25, 2008

CNMI Department of Public SafetyDriver Education Instructor Application

PAGE

DEPARTMENT OFPUBLIC SAFETY

Initial ApplicationRenewal Instructor Certificate Number

YES NO Have you completed the the required cardio-Pulmonary Resuscitation (CPR) course? (If answered YES, state the name and location of the training facility plus the dates of attendance and completion. A copy of the certicate must accompany this application.)

Name of Training Facility Location

Date of CompletionDates of Attendance

Name of High School(s) Attended Dates Attended

Dates Attended

Major/Minor Degree

Date of Graduation Dates Attended

Major/Minor Degree

Type of CertificateDates Attended

Specific Skills Acquired

Specific Skills Acquired

Dates Attended Type of Certificate

Date of Graduation

Date of Graduation

GED Diploma Location

College or University

College or University

Additional Training Facilities

Additional Training Facilities

Location

Location

Location

Location

Name (First, Middle, Last)

Postal Address

Physical Address

Home Telephone Number

E-Mail Address

Driver Education School

Types of Vehicles Used for Instruction

Automobiles Taxis Trucks Buses Motorcycles Others

Explain “Others”

Cellular NumberTelephone Number

Praxis II Test Score (attach test results)

License Class(es)Cellular Number

Praxis II Test Name and Number

Physical Address

CNMI Driver License Number

Date of Birth

Social Security Number

Gender (Male/Female)

Date of Expiration

Years of DrivingExperience

Education and Training:

Page 1April 2008

Employment History (last five years):

Name on Firm Address

Address

Address

Dates of Employment

Contact Information

Contact Information

Contact Information

Reason for Leaving

Reason for Leaving

Reason for Leaving

Dates of Employment

Dates of Employment

Name on Firm

Name on Firm

Kind of Work

Kind of Work

Kind of Work

Do you possess a valid CNMI driver’s license with the classification andendorsements required for the operation of the class and type of motor vehicleused in driver education?

Have you had a valid driver’s license recognized by the Commonwealth for atleast five (5) years?

Are you at least twenty-one (21) years of age?

Do you possess a high school diploma or its equivalent?

Have you completed the National Safety Council’s Defensive Driving course?

Have you passed the Driver Education Praxis II exam (0867) with a score of atleast 171 or the Safety/Driver Education Praxis II exam (0860) (for SeniorInstructors) with a score of at least 590?

Have you had a driving under the influence of alcohol or drug conviction withinfive (5) years prior to applying for, or obtaining certification? Have you had your driver’s license suspended, revoked, cancelled, ordisqualified within three (3) years prior to applying for or obtaining certification Have you ever been convicted of a felony or a crime involving violence,dishonesty, deceit, indecency, degeneracy, or moral turpitude? Do you possess any criminal record that would make you unsuitable to workwith children and/or young adults? Do you have any physical impairment that could hinder your ability to performthe duties of a driving instructor?

In the past: year, have you had a loss of consciousness or muscle control,caused by any of the following conditions?

Have you had more than one moving traffic violation within one (1) year prior toapplying for, or obtaining certification; not more than two moving traffic violationswithin three (3) years prior to applying for, or obtaining certification; and notmore than three moving traffic violations within five (5) years prior to applyingfor, or obtaining certification?

Questions:

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES NO

Brain or Head Injury

Muscle or Nerve Diabetes

Heart Mental

Lung Sleeping Disorder

Seizure Disorder

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

12.

13.

11.

COMMONWEALTH REGISTER VOLUME 30 NUMBER 04 April 25, 2008

CNMI Department of Public SafetyDriver Education Instructor Application

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Page 2April 2008

If you answered “YES” to questions #7 13 on the previous page, provide the details of each ofthose questions on the lines below.

CONDITIONS

As a condition for the issuance and the continued effect of a Driver Education Instructorcertificate, the undersigned undertake and agree to all of the following conditions:

I will carry my instructor’s certificate at all times while giving driving instructions.

If i lose my certificate, I will report the loss immediately to the Bureau of Motor Vehicles.

If my driver’s license is suspended or revoked, my instructor certificate is not valid, and Imust surrender it immediately to the Bureau of Motor Vehicles.

If the Bureau of Motor Vehicles determines that I am not or no longer entitled to mycertificate, I must surrender it immediately to the Bureau of Motor Vehicles.

I understand that my instructor certificate will expire one (1) year from the date ofissuance, unless suspended or revoked by the Bureau of Motor Vehicles.

I understand that I must apply for the renewal of my instructor certificate not more thansixty (60) days or less than thirty (30) days prior to the expiration of the certificate.

I will only use vehicles for laboratory instruction that have been properly equipped andapproved by the Department of Public Safety.

I will follow the approved written classroom and laboratory curriculums.

PRINT/TYPE Name of Instructor Application

Sworn to before me this day

, .of

(Notary Public) (Seal Required)

My commission expires:

Signature

Date

I will comply with all of the provisions of the Department of Public Safety’s Rules and Regulations for driver education schools.

I understand that any misrepresentative or concealed material facts will be sufficient cause fordenial or suspension of my certificate. I further understand that any conduct resulting in violationof the laws governing driver education instructors will be just cause for revocation od suspensionof my certificate or other sactions as set forth in Public Law #15-25 and the Department ofPublic Safety’s Rules and Regulations for driver education scholls.

I certify under penalty of perjury under the laws of the Commonwealth of the Northern MarianaIslands that the foregoing is true and correct.

A.

B.

C.

D.

E.

F.

G.

H.

I.

COMMONWEALTH REGISTER VOLUME 30 NUMBER 04 April 25, 2008

CNMI Department of Public SafetyDriver Education Instructor Application

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Page 3April 2008