Driver Training Pre-Registration Form

FORM COMPLETION INSTRUCTIONS:

***** Fill in ALL information (required) *****

Stop Man

In order to complete this form, you MUST have your AGENCY'S BUDGET ACCOUNT #. If you require more information in this regard please contact your Department's Driver Coordinator.
Important Information

If you live in Maryland but have an out-of-state Driver's License, you MUST transfer to a Maryland Driver's License prior to attending either class. If you DO NOT live in Maryland, you must include a scanned copy of your out-of-state driving record along with the registration form. Each 6 months you are required to submit a copy to our office.
If, in the event that you DO NOT pass the standard eye exam, you are required to obtain a note from your doctor indicating that you have passed. You MUST submit the signed and approved doctor's note within 30 days of the class to their Department's Driver Coordinator. The fill-in-the-blank note may be found at - www.marylandmva.com/Resources/DL-043A.pdf
IF, APPLICABLE PLEASE BRING YOUR OLD DRIVING PERMIT AND EYEGLASSES TO CLASS WITH YOU.

Division of Occupational Safety|401 E. Fayette Street, Suite 700|Phone: (410) 396-3738

FOR DOS USE ONLY

Date Confirmation Sent:

Initials:

REGISTRANT INFORMATION

Today's Date: *

Last Name: *

First Name: *

Middle Initial:

Job Title: *

Agency Budget Account #: *

Agency code: A-

Basic Class Date:

Re-certification Class Date:

Department: *

Are You - School Police/Sheriff/Other ? Please Specify: *

Work Address: *

Phone Number *

Permit Number

Permit Expiration Date:

Month

Day

Year

MD State Driver's License Number: *

Expiration Date *

Month

Day

Year

Class: *

Sex: *

Age: *

Date of Birth: *

List any special equipment that you are required to operate that may or may not require a CDL:

DRIVING PRIVILEGES

Have your driving privileges been suspended or revoked within the last 7 years and/or do you currently have any points on your Maryland State driving record? *

Yes

If yes, list each incident and a brief account of the circumstances leading up to the incident.

Leave this field blank

Baltimore City Department of Finance

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Driver Training Pre-Registration Form