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Driver’s License Academy Enrollment Verification Request Form

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Driver’s License Academy Enrollment Verification Request Form

* Indicates a required field

First name *

Last name *

Date of birth *

Month

Day

Year

Phone number *

Best phone number to reach the person requesting assistance.

Email address *

Email address of the person requesting assistance.

Street address *

City *

Zip Code *

Race/ethnicity *

American Indian or Alaska Native

African American or Black

Asian

Hispanic or Latino

White

Native Hawaiian or Other Pacific Islander

Other

If other, please describe race/ethnicity

Name of Credentialed or certificate career pathway, job training program or industry exploration program *

Field of credentialed or certificate career pathway, job training program or industry exploration program *

Automotive

Construction

Health or Human Services

Manufacturing

Other

If other, please describe field of program

Name of Certifying Official (first and last) *

Email of Certifying Official *

Employment Barrier(s) *

Select all that apply.

Age 18-24

Unlikely or unable to obtain or retain desired employment due to not having a driver’s license

Household income below 200% federal poverty

Justice/Foster Care or Child Welfare system involvement

Homeless or unsheltered

Individualized Education Plan (IEP)

English Language Learner

Other

If other, please describe employment barrier(s)

Services Requested *

Select all that apply.

Tutoring support for Class D Instruction Permit

Support obtaining Class D Instruction Permit

Behind-The-Wheel (6 hours)

Vechicle for class D road test

Fee for class D road test (Cannot be used to pay fines and fees related to a suspended license)

Preferred language if other than English

By selecting, you are certifying that you are enrolled in a credentialed or certificate career pathway, job training program or industry exploration program that requires a driver’s license for employment and that you are seeking and available to work full-time. *

I certify.

Job seeker agrees to maintain contact with licensed commercial driving training school including notifying driving school if you are unable to keep a scheduled appointment . *

I agree.

Job seeker agrees to complete required behind the wheel training hours. *

I agree.

Job seeker agrees to full time employment opportunities and be available to work full time. *

I agree.

Job seeker agrees to notify Ramsey County Driver’s Academy Coordinator and commercial driving school of any changes in status – address, phone, change in training plans. *

I agree.

I authorize Ramsey County Workforce Solutions to release information to and request information (commercial driving training, third party payment/documentation or other) regarding vocation planning. I understand that my records are protected under the Minnesota Data Practices Act and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time by written notice. I understand that my revocation may not be made retroactive and will not apply where action had been taken in reliance upon it (e.g., probation, parole, etc.). This consent automatically expires one year after my file has been exited from the program. *

I authorize

Today's date *

Month

Day

Year

Leave this field blank

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