Driver Improvement Waiver


Participant Waiver and Release


Participant Soundex Number (Driver's License Number)


Participant Name:    

Participant Date of Birth:                             



By my signature below, I acknowledge that:

  • I furnished the Motor Vehicle Administration letter of assignment to the driver
    improvement program provider; and if not:




  • Electronic certification of completion of this program is based solely on the accuracy of the
    information I provided to the driver improvement program provider on this form; and
  • I have been provided a copy of the Driver Improvement Program Participant Roles and
    Responsibilities; and
  • I fully understand my responsibility in assuring that my driving record properly reflects my
    completion of this program



May 5, 2021


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Signature Certificate
Document name: Driver Improvement Waiver
lock iconUnique Document ID: bbca01ea198fbe7ad65f0e4ea4bc9535be724596
Timestamp Audit
December 1, 2020 2:42 pm EDTDriver Improvement Waiver Uploaded by Premier Driving School, Inc - IP