Attachment D - Driver Training Certification questions

U.S. Department of Transportation
Federal Motor Carrier
Safety Administration

DRIVER TRAINING CERTIFICATION INFORMATION
1. Training provider business name:

2. Training Provider Registry Identification Number:

3. Driver-trainee name:

5. Driver-trainee State of licensure:

Type of Training Completed  
(Enter Completion Date For All that Apply) 
Class A (Theory & BTW)
Class A (Theory Only) 
Class A (BTW Only)
Class B to A Upgrade (Theory & BTW)
Class B to A Upgrade (Theory Only) 
Class B (Theory & BTW)
Class B (Theory Only) 
Class B (BTW Only)
Passenger (Theory & BTW)
Passenger (Theory Only) 
Passenger (BTW Only)
School Bus (Theory & BTW)
School Bus (Theory Only) 
School Bus (BTW Only)
Hazardous Materials (Theory Only) 

4. Driver-trainee date of birth (MM/DD/YYYY)

6. Driver-trainee driver license number:

Total Number of   
BTW Clock Hours 

Completion Date 
(MM/DD/YYYY)