To confidentially report waste, fraud or abuse by any DC Government Agency or official, call the DC Inspector General at 1-800-521-1639.
DC DMV-PRA-001 Version 11/2015
Is the applicant or any owner, partner, officer, or other person directly interested in the business an employee of the
Department of Motor Vehicles whose employment is directly related to the issuance of any license? YES NO
Is the applicant or any owner, partner, officer, or other person directly interested in the business on parole or probation at
the time of application? YES NO
IF YES, please explain in additional information section.
Is the applicant or any owner, partner, officer, or other person directly interested in the business been convicted of, is
serving a sentence for, or is under indictment for committing or attempting to commit a misdemeanor? YES NO
IF YES, please explain in additional information section.
Is the applicant or any owner, partner, officer, or other person directly interested in the business been convicted of, is
serving a sentence for, or is under indictment for committing or attempting to commit a sex offense? YES NO
IF YES, please explain in additional information section.
If any responses require additional information, please provide information here:
_________________________________________________________________________________________________
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REQUIRED DOCUMENTATION CHECKLIST:
Business License or Occupancy Permit reflecting classroom location address
District of Columbia Clean Hands Certification (http://dcra.dc.gov/publication/dcra-clean-hands-self-certification-
form)
Certificate of General Liability Insurance
Certificate of Insurance for Vehicle Insurance (required for all instructional vehicles)
Fingerprints obtained from Metropolitan Police Department or Local Jurisdiction (required for all Owners, Officers,
and Instructors)
Copy of Instructor License (Instructors Only)
5 Year Driver Record (Instructors Only)
Copy of Vehicle Registration (required for all instructional vehicles)
Any person using a fictitious name or address and knowingly making any false statement on this application is in violation of DC Law and subject to a
fine of not more than $1,000 or 180 days imprisonment or both. (D.C. Official Code §22-2405)
I hereby certify that the information contained on this application is true and correct.
Applicant’s Signature: Date: _______________
Applicant’s Name: _______________
For DMV Official Use Only
DATE REC:________________________________ BATCH NUM:______________________
APPROVED:_______________________________ ISSUE DATE:____________ EXP DATE:___________
DMV REP:_________________________________