Form R-7A "Driver Training Instructor's License Application" - Connecticut

What Is Form R-7A?

This is a legal form that was released by the Connecticut Department of Motor Vehicles - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2013;
  • The latest edition provided by the Connecticut Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form R-7A by clicking the link below or browse more documents and templates provided by the Connecticut Department of Motor Vehicles.

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Download Form R-7A "Driver Training Instructor's License Application" - Connecticut

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DRIVER TRAINING INSTRUCTOR'S
STATE OF CONNECTICUT
LICENSE APPLICATION
DEPARTMENT OF MOTOR VEHICLES
R-7A REV. 2-2013
DRIVER EDUCATION UNIT
NAME OF APPLICANT
D M V U S E O N L Y
RESIDENT ADDRESS
(Number and Street)
INSTRUCTOR NUMBER INSPECTOR BADGE NO.
DATE
(City or Town)
(State)
(Zip Code)
LICENSE
FEE COLLECTED
INITIAL
RENEWAL
DUPLICATE
MAILING ADDRESS (If different)
SEX
HEIGHT
WEIGHT
MALE
FEMALE
SCHOOL TYPE APPLYING FOR
DATE OF BIRTH
EYE COLOR
HAIR COLOR
SECONDARY/VOCATIONAL
COMMERCIAL DRIVING
OTHER (Explain)
NAME OF SCHOOL FOR WHICH YOU INTEND TO TEACH
HAVE YOU HAD A MOTOR VEHICLE
STATE
OPERATOR'S LICENSE FOR THE PAST
YES
NO
FOUR (4) CONSECUTIVE YEARS?
ADDRESS OF SCHOOL FOR WHICH YOU INTENTED TO TEACH
(Number and Street)
OPERATOR LICENSE NUMBER
(City or Town)
(State)
(Zip Code)
SOCIAL SECURITY NUMBER
Please answer all questions below to the best of your ability. Applicants providing false information are subject to prosecution to the fullest extent of the law.
1. HOW LONG HAVE YOU RESIDED IN THE TOWN OR CITY LISTED ABOVE?
2. WHERE WAS YOUR PREVIOUS PLACE OF RESIDENCE?
3. DO YOU HAVE A HIGH SCHOOL DIPLOMA OR EQUIVALENCY CERTIFICATE ISSUED BY THE STATE BOARD OF EDUCATION (If yes, provide name of high school or Board of Education certificate
number.)
4.
HAVE YOU BEEN TREATED FOR FAINTING SPELLS, DIZZINESS, HEART DISEASE,
5. HAS YOUR OPERATOR'S LICENSE OR REGISTRATION PRIVILEGES EVER BEEN REFUSED,
SEIZURES OR OTHER DISABILITIES? (If yes, explain below.)
REVOKED, OR SUSPENDED BY ANY STATE? (if yes, indicate where, when, and why below.)
6. DO YOU HAVE AN ADDICTION TO ALCOHOL AND/OR OTHER DRUGS.
7. ARE YOU REQUIRED TO TAKE DRUGS ON A REGULAR BASIS FOR A MEDICAL CONDITION
THAT MAY AFFECT YOUR ABILITY TO DRIVE?
8. HAVE YOU EVER BEEN CONVICTED OF A VIOLATION OF LAWS OTHER THAN THOSE
9.
HAVE YOU EVER BEEN CONVICTED FOR VIOLATIONS OF LAWS, REGULATIONS, OR
PERTAINING TO THE USE OF A MOTOR VEHICLE? (If yes, explain.)
ORDNANCES OF ANY STATE PERTAINING TO USE OF A MOTOR VEHICLE? (If yes, explain)
WHERE COMPLETED
WHEN COMPLETED
CLASSROOM HOURS
BEHIND THE WHEEL HOURS
10. HAVE YOU COMPLETED AN APPROVED 45
HOUR INSTRUCTORS TRAINING COURSE?
WHERE COMPLETED
WHEN COMPLETED
CLASSROOM HOURS
BEHIND THE WHEEL HOURS
11.
HAVE YOU COMPLETED AN APPROVED
ADDITIONAL 45 HOURS OF TRAINING?
I, the undersigned, declare under penalty of false statement that I have truthfully answered and/or provided all requested information to the best of my knowledge and
ability.
APPLICANT'S SIGNATURE
DATE SIGNED
X
WITNESS/SCHOOL OWNER SIGNATURE
DATE SIGNED
X
CERTIFICATE OF EMPLOYMENT
This is to certify that the undersigned is employed in a secondary/vocational school system/or commercial driver education program in which the applicant will
teach/instruct driver education in a DMV approved program.
SCHOOL NAME AND ADDRESS
PHONE NUMBER
DATE SIGNED
SCHOOL ADMINISTRATOR SIGNATURE
TITLE
DATE SIGNED
X
EXAMINATION RESULTS - DMV USE ONLY
DATE OF ROAD TEST
R-250 ATTACHED
BOTH
LEFT
RIGHT
V
PASSED
REJECTED
WITHOUT GLASSES
I
DATE OF RETEST
R-250 ATTACHED
S
WITH GLASSES
PASSED
REJECTED
NUMBER OF RETEST
I
COLOR
SECOND
FIRST
THIRD
O
RESTRICTED
N
NOTE:
ATTACH CRIMINAL HISTORY INVESTIGATION RESULTS
DEPTH PERCEPTION
INSPECTOR'S SIGNATURE
TITLE
DATE SIGNED
X
DMV ADMINISTRATOR'S SIGNATURE
TITLE
DATE SIGNED
X
DRIVER TRAINING INSTRUCTOR'S
STATE OF CONNECTICUT
LICENSE APPLICATION
DEPARTMENT OF MOTOR VEHICLES
R-7A REV. 2-2013
DRIVER EDUCATION UNIT
NAME OF APPLICANT
D M V U S E O N L Y
RESIDENT ADDRESS
(Number and Street)
INSTRUCTOR NUMBER INSPECTOR BADGE NO.
DATE
(City or Town)
(State)
(Zip Code)
LICENSE
FEE COLLECTED
INITIAL
RENEWAL
DUPLICATE
MAILING ADDRESS (If different)
SEX
HEIGHT
WEIGHT
MALE
FEMALE
SCHOOL TYPE APPLYING FOR
DATE OF BIRTH
EYE COLOR
HAIR COLOR
SECONDARY/VOCATIONAL
COMMERCIAL DRIVING
OTHER (Explain)
NAME OF SCHOOL FOR WHICH YOU INTEND TO TEACH
HAVE YOU HAD A MOTOR VEHICLE
STATE
OPERATOR'S LICENSE FOR THE PAST
YES
NO
FOUR (4) CONSECUTIVE YEARS?
ADDRESS OF SCHOOL FOR WHICH YOU INTENTED TO TEACH
(Number and Street)
OPERATOR LICENSE NUMBER
(City or Town)
(State)
(Zip Code)
SOCIAL SECURITY NUMBER
Please answer all questions below to the best of your ability. Applicants providing false information are subject to prosecution to the fullest extent of the law.
1. HOW LONG HAVE YOU RESIDED IN THE TOWN OR CITY LISTED ABOVE?
2. WHERE WAS YOUR PREVIOUS PLACE OF RESIDENCE?
3. DO YOU HAVE A HIGH SCHOOL DIPLOMA OR EQUIVALENCY CERTIFICATE ISSUED BY THE STATE BOARD OF EDUCATION (If yes, provide name of high school or Board of Education certificate
number.)
4.
HAVE YOU BEEN TREATED FOR FAINTING SPELLS, DIZZINESS, HEART DISEASE,
5. HAS YOUR OPERATOR'S LICENSE OR REGISTRATION PRIVILEGES EVER BEEN REFUSED,
SEIZURES OR OTHER DISABILITIES? (If yes, explain below.)
REVOKED, OR SUSPENDED BY ANY STATE? (if yes, indicate where, when, and why below.)
6. DO YOU HAVE AN ADDICTION TO ALCOHOL AND/OR OTHER DRUGS.
7. ARE YOU REQUIRED TO TAKE DRUGS ON A REGULAR BASIS FOR A MEDICAL CONDITION
THAT MAY AFFECT YOUR ABILITY TO DRIVE?
8. HAVE YOU EVER BEEN CONVICTED OF A VIOLATION OF LAWS OTHER THAN THOSE
9.
HAVE YOU EVER BEEN CONVICTED FOR VIOLATIONS OF LAWS, REGULATIONS, OR
PERTAINING TO THE USE OF A MOTOR VEHICLE? (If yes, explain.)
ORDNANCES OF ANY STATE PERTAINING TO USE OF A MOTOR VEHICLE? (If yes, explain)
WHERE COMPLETED
WHEN COMPLETED
CLASSROOM HOURS
BEHIND THE WHEEL HOURS
10. HAVE YOU COMPLETED AN APPROVED 45
HOUR INSTRUCTORS TRAINING COURSE?
WHERE COMPLETED
WHEN COMPLETED
CLASSROOM HOURS
BEHIND THE WHEEL HOURS
11.
HAVE YOU COMPLETED AN APPROVED
ADDITIONAL 45 HOURS OF TRAINING?
I, the undersigned, declare under penalty of false statement that I have truthfully answered and/or provided all requested information to the best of my knowledge and
ability.
APPLICANT'S SIGNATURE
DATE SIGNED
X
WITNESS/SCHOOL OWNER SIGNATURE
DATE SIGNED
X
CERTIFICATE OF EMPLOYMENT
This is to certify that the undersigned is employed in a secondary/vocational school system/or commercial driver education program in which the applicant will
teach/instruct driver education in a DMV approved program.
SCHOOL NAME AND ADDRESS
PHONE NUMBER
DATE SIGNED
SCHOOL ADMINISTRATOR SIGNATURE
TITLE
DATE SIGNED
X
EXAMINATION RESULTS - DMV USE ONLY
DATE OF ROAD TEST
R-250 ATTACHED
BOTH
LEFT
RIGHT
V
PASSED
REJECTED
WITHOUT GLASSES
I
DATE OF RETEST
R-250 ATTACHED
S
WITH GLASSES
PASSED
REJECTED
NUMBER OF RETEST
I
COLOR
SECOND
FIRST
THIRD
O
RESTRICTED
N
NOTE:
ATTACH CRIMINAL HISTORY INVESTIGATION RESULTS
DEPTH PERCEPTION
INSPECTOR'S SIGNATURE
TITLE
DATE SIGNED
X
DMV ADMINISTRATOR'S SIGNATURE
TITLE
DATE SIGNED
X