Form PS36008-10 "Application for Driver Training Instructor's License" - Minnesota

What Is Form PS36008-10?

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

Form Details:

  • Released on October 1, 2016;
  • The latest edition provided by the Minnesota Department of Public Safety;
  • 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 PS36008-10 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Public Safety.

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Download Form PS36008-10 "Application for Driver Training Instructor's License" - Minnesota

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For Office Use Only
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MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
A P P LI C A TION FOR DRI VER T R A IN IN G IN S TRUCT OR'S L ICE NSE
No license fee will be refunded in the event the application is disapproved. An instructor license is issued under Minnesota Statutes, Sections 171.33-171.41, and Minnesota Rules, Parts 7411.0100 to 7411.2000.
Part A - IDENTIFICATION DATA (To be completed by the Applicant)
Last Name
First Name
Middle Name
Birth Date (M/D/YYYY)
Permanent Street Address
City
State
Zip Code
Driver's License Number
Social Security Number (Required Minn. Stat. 270C.72)
Home Telephone Number
• Certified out-of-state driver's license record, if necessary
ATTACH A COPY OF:
• High school diploma or equivalency certificate (initial application only)
• Fingerprint card and fee made payable to the BCA (initial application only)
Name & Address of Commercial Driver Training School at which you will be employed:
List Below Your Education and Training for a Driver Training Instructor's License (initial application only)
DATE CLASSROOM COMPETENCIES IN MINNESOTA
DATE LABORATORY COMPETENCIES IN MINNESOTA
NAME & LOCATION OF TRAINING PROVIDER
RULES, PART 7411.0630 COMPLETED
RULES, PART 7411.0630 COMPLETED
Part B - (To be completed and signed)
Important facts about information on this application in compliance
Authorized Official of the Driver
Applicant:
with M.S. 13.04, subd. 2:
Training School:
I certify that the information contained in this statement is true,
This application for a driver training instructor’s license is to help determine eligibility.
accurate, and complete, and that:
I certify that the above named applicant has
Information other than your name and address requested on the application is private;
completed the training competencies in
that is, it may be released only to you or with your permission.
I meet the instructor qualifications in Minnesota Rules, Part
Minnesota Rules, Part 7411.0630, and is or will
It is necessary for you to complete the entire application; failure to do so will result in
7411.0620; and
be an instructor at our Driver Training School.
the disapproval of the application.
My driving history exempts me from the disqualification
The information contained herein may be shared with authorized persons in the
criteria in Minnesota Rules, Part 7411.0645.
Department of Public Safety and the Attorney General’s Office of the State of
Minnesota.
If a license is issued, the privacy status of the information may change in compliance
with Minnesota statutes. All information then becomes public with the exception of:
Applicant's Signature
Authorized Official's Signature
1.
Medical reports of applicants for commercial driver training instructor’s
license (M.S. 13.69, subd. 1).
2.
Information about a complaint against a licensee or applicant if the complaint
is unsubstantiated or investigation is inactive (M.S. 13.41, subd. 2).
Date
Date
3.
Inactive investigative data relating to the violation of statutes or rules (M.S.
13.41, subd. 2).
(OVER)
PS36008-10 (10/16)
For Office Use Only
Print Form
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
A P P LI C A TION FOR DRI VER T R A IN IN G IN S TRUCT OR'S L ICE NSE
No license fee will be refunded in the event the application is disapproved. An instructor license is issued under Minnesota Statutes, Sections 171.33-171.41, and Minnesota Rules, Parts 7411.0100 to 7411.2000.
Part A - IDENTIFICATION DATA (To be completed by the Applicant)
Last Name
First Name
Middle Name
Birth Date (M/D/YYYY)
Permanent Street Address
City
State
Zip Code
Driver's License Number
Social Security Number (Required Minn. Stat. 270C.72)
Home Telephone Number
• Certified out-of-state driver's license record, if necessary
ATTACH A COPY OF:
• High school diploma or equivalency certificate (initial application only)
• Fingerprint card and fee made payable to the BCA (initial application only)
Name & Address of Commercial Driver Training School at which you will be employed:
List Below Your Education and Training for a Driver Training Instructor's License (initial application only)
DATE CLASSROOM COMPETENCIES IN MINNESOTA
DATE LABORATORY COMPETENCIES IN MINNESOTA
NAME & LOCATION OF TRAINING PROVIDER
RULES, PART 7411.0630 COMPLETED
RULES, PART 7411.0630 COMPLETED
Part B - (To be completed and signed)
Important facts about information on this application in compliance
Authorized Official of the Driver
Applicant:
with M.S. 13.04, subd. 2:
Training School:
I certify that the information contained in this statement is true,
This application for a driver training instructor’s license is to help determine eligibility.
accurate, and complete, and that:
I certify that the above named applicant has
Information other than your name and address requested on the application is private;
completed the training competencies in
that is, it may be released only to you or with your permission.
I meet the instructor qualifications in Minnesota Rules, Part
Minnesota Rules, Part 7411.0630, and is or will
It is necessary for you to complete the entire application; failure to do so will result in
7411.0620; and
be an instructor at our Driver Training School.
the disapproval of the application.
My driving history exempts me from the disqualification
The information contained herein may be shared with authorized persons in the
criteria in Minnesota Rules, Part 7411.0645.
Department of Public Safety and the Attorney General’s Office of the State of
Minnesota.
If a license is issued, the privacy status of the information may change in compliance
with Minnesota statutes. All information then becomes public with the exception of:
Applicant's Signature
Authorized Official's Signature
1.
Medical reports of applicants for commercial driver training instructor’s
license (M.S. 13.69, subd. 1).
2.
Information about a complaint against a licensee or applicant if the complaint
is unsubstantiated or investigation is inactive (M.S. 13.41, subd. 2).
Date
Date
3.
Inactive investigative data relating to the violation of statutes or rules (M.S.
13.41, subd. 2).
(OVER)
PS36008-10 (10/16)
Date:
The following named individual has made application with this agency for a driver training instructor’s license.
Applicant
Last Name:
First Name:
Middle (full) Name:
Maiden, Alias, or Former Name:
Date of Birth:
Sex (M or F):
I authorize the Minnesota Bureau of Criminal Apprehension and the Federal Bureau of Investigation to disclose all criminal
history record information to the Minnesota Department of Public Safety, Driver and Vehicle Services, Office of Driver Education
for the purpose of obtaining a driver training instructor’s license from this agency. This background check is being done in
accordance with Minnesota Rules 7411.0620, Subpart 8. and MnSA 171.
The expiration of this authorization shall be one year from the date of my signature.
Date
Applicant's Signature
To the Applicant:
Please be advised:
• Records obtained under the authority cited above may be used solely for the purpose requested.
• Your fingerprints will be used to identify fingerprint supported records, including criminal history, at the Minnesota BCA and the FBI.
• You have the right to challenge the accuracy and completeness of information provided (procedures are set forth in Minnesota Statutes section 13.04 and Title 28
CFR Section 16.34).
Submit this application and the license fee of $50.00 made payable to the Commissioner of Public Safety to:
Driver & Vehicle Services
Office of Driver Education
445 Minnesota Street, Suite 176
St. Paul, MN 55101-5176
PS36008-10 (10/16)
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