Regional Training Center Instructor Application

Applicant Name *

First

Last

Date of Birth *

Mailing Address *

City, State, Zip Code *

First

Middle

Last

Driver's License Number & State *

First

Last

Phone Number *

Contact Name to

Email Address *

Employer / Driving Enterprise Name *

Employer / Driving Enterprise Contact Person *

Employer / Driving Enterprise Phone Number *

Employer / Driving Enterprise Email *

I am interested in the following Class D Licensure:

Driver Training Instructor (Full Licensure)
Restricted Classroom Instructor
Restricted Behind-the-Wheel Instructor

ELIGIBILITY CONFIRMATION: Eligibility is subject to verification and approval. The following must be provided by the applicant / Driving Enterprise: (Click box to accept) *

An official driving record provided by the Ohio BMV or if applicant resides in another state, an official driving abstract from the state’s DMV/BMV.
BCI & FBI - A state and federal background check from the state of residence. Cannot be dated more than six months from date of application.

ACHNOWLEDGEMENT (Click box to accept and approve the below requirement) *

As the prospective instructor applicant, I understand and acknowledge that this application is for the purposes of the Ohio Instructor Development Grant. I acknowledge that the final eligibility and enrollment decisions are made by the Training Center. I agree to provide any additional documentation requested to verify my eligibility. I certify that the information provided is true and accurate to the best of my knowledge. I understand that falsification may result in disqualification from the grant program.

AUTHORIZATION TO OBTAIN AND RELEASE INFORMATION (Click box to accept and approve the below requirement) *

Training records will be shared with the Ohio Traffic Safety Office (OTSO) for grant compliance purposes. No personal data will be disclosed beyond what is required. I hereby grant permission for the release of my records, including but not limited to, this application and pre-requisites, and the records as part of the training provided thereafter.

Applicant Certification / Agreement Statement