defensive driving certification application for initial

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ARIZONA SUPREME COURT

DEFENSIVE DRIVING CERTIFICATION

APPLICATION FOR INITIAL CERTIFICATION AS A

BUSINESS ENTITY

Any willful omission or misrepresentation of any fact required to be disclosed in this application, or any accompanying statement, is grounds for refusing to issue or renew a certificate or for revoking or suspending a certificate. This document can be made available in large format or on audio tape upon request. Please contact the Certification and Licensing Division at (602) 452-3378 or (602) 452-3545 (TDD).

INSTRUCTIONS: 1. CAREFULLY READ THE ADDITIONAL INSTRUCTIONS AND INFORMATION ON PAGE

18. 2. Application must be completed online, printed and submitted to the Arizona Supreme

Court. Any form that requires completion by hand must be done in black ink. 3. The Designated Principal of the business must complete ALL PAGES and SUBMIT

ALL DOCUMENTATION requested on this form. 4. If any section of this application does not apply, indicate by “N/A”. 5. Applicants applying for alternative delivery method format must also complete a

separate “Addendum to Business Entity Certification Application for Alternative Delivery Method (ADM) Format.”

Note: Any information provided on pages 1-4 may be confidential pursuant to Court Rule. .

SECTION I: APPLICANT INFORMATION.

Organization Legal Name:

List ALL assumed, DBA’s or trade names:

Business Address to appear on certificate and Judicial Website: (Street Address) (City) (State) (Zip)

Business Telephone Number:

Business Fax Number: ( )

Business E Mail Address:

Date business formed: (Month/Day/Year)

Federal Tax ID Number:

State Tax ID Number:

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Check appropriate business organization: NOTE: Copies of Articles of Incorporation/Organization and a Certificate of Good Standing issued from the Arizona Corporation Commission or Partnership Agreements MUST be attached, as applicable.

Designated Principal’s Full Name:

Designated Principal’s Home address:

(Street Address) (City) (State) (Zip)

Home Telephone Number:

Social Security Number:

SECTION II: BUSINESS ENTITY MEMBER(S) INFORMATION. Provide the following information for ALL Members, Partners, Managers, Officers, Directors, and Owners (add additional pages, if necessary).

Legal Last Name, Full First Name, Full Middle Name: Corporate Title/Position:

Address - Physical Street Address (may not be a P.O. box): (Street Address) (City) (State) (Zip)

Home Telephone Number: Social Security Number:

Does this individual have contract negotiation authority? Yes No






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SECTION III: CERTIFIED DEFENSIVE DRIVING INSTRUCTORS: [Note: a business must have at least one certified instructor of the applicant school’s curriculum on its staff in order to be certified per ACJA

§ 7-205(E)(1)(o) and (p). List ALL individuals who are certified defensive driving instructors on behalf of the business entity. If an individual has an application pending for individual certification, write “pending” in the Certification # box and mark the “Yes” box after “Trainee.” Add additional pages if necessary immediately behind this page of the application.

Legal Last Name, Full First Name, Full Middle Name:

Home Address - Physical Street Address (may not be a P.O. box): (Street Address) (City) (State) (Zip)

Certification #: Trainee: Yes No










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NAME OF BUSINESS ENTITY: ____________________________________________________________________________ SECTION IV: BUSINESS DESCRIPTION OF BUSINESS ORGANIZATION.

Provide a brief description of the general nature of the business being conducted:

SECTION V: DEFENSIVE DRIVING RELATED ACTIVITIES PERFORMED.

List the defensive driving related experience of the business if not listed in the Business Description Section above:

List ALL locations where this business is providing defensive driving courses : (Street) (City) (State) (Zip)

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Other occupational and professional licenses or certifications held by the business entity related to presenting defensive driving courses: Expiration date:

SECTION VI: APPLICANT BACKGROUND INFORMATION. If you answer “Yes” to any question in this section:

You must send a list of all incidents and complete a written explanation of the events for each. This includes incidents which may be pending and/or in litigation, and

You must send any and all documentation which shows where the violation, finding, or conviction occurred, the nature and details of the case, case disposition, court, case number, and any other relevant information.

Attach additional sheets, if necessary.

Failure to forward a written statement may result in the delay of processing your application for renewal, expiration of your certificate, late fees assessed, and/or denial of your application for renewal. SECTION VII: APPLICANT BACKGROUND INFORMATION (continued). Note: Starting with this page, do not include personal identifying information (social security number, date of birth, home address, etc.) in the application or in any response to questions from this point forward Has the business entity, designated principal or ANY officer, director, partner, member, manager, or owner:

Ever been found guilty of any felony or misdemeanor?

(The fact that the officer, director, partner, member, manager, or owner entered into a plea bargain or pled “no contest”, or that the conviction has been vacated, pardoned, expunged, dismissed, or appealed, or that the civil rights have been restored does not mean that the question can be answered no. If the answer is yes, give details of the offense, and explain. Do not answer yes or give details if the offenses are only minor civil traffic violations.)

Yes No

Committed material misrepresentation, omission, fraud, dishonesty, or corruption in applying for a certificate or on a certificate examination in this state or any other state?

Yes No

Committed any act constituting material misrepresentation, omission, fraud, dishonesty or corruption in business or financial matters?

Yes No

Had conduct showing incompetence or a source of injury and loss to the public?

Yes No

Been convicted by final judgment of a felony, regardless of whether civil rights have been restored?

Yes No

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Been convicted by final judgment of a misdemeanor, regardless of whether civil rights have been restored?

Yes No

Had a professional or occupational license or certificate denied revoked, suspended or any disciplinary action taken?

Yes No

Had a professional or occupational license or certificate censured, placed on probation, or any disciplinary action taken?

Yes No

Been terminated, suspended, place on probation, or other disciplinary action taken in past or present employment?

Yes No

Been found civilly liable in an action involving misrepresentation, material omission, fraud, misappropriation, theft or conversion?

Yes No

Currently on probation or parole? Yes No

Violated any decision, order, or rule issued by a professional regulatory entity?

Yes No

Violated any order of a court, judicial officer, administrative tribunal, or the Board?

Yes No

Made a false or misleading statement or verification in support of an application for a certificate filed by another person?

Yes No

Made a false or misleading oral or written statement to division staff or the Board?

Yes No

Failed to disclose information on the certification application subsequently revealed through a background check?

Yes No

Failed to respond or furnish information to division staff or the Board when the information is legally requested and is in your control or is reasonably available to you and pertains to certification or investigative inquiries?

Yes No

Been a record of conduct constituting or investigative inquiries; or fraud on the part of an employee, board member, or the business?

Yes No

Been or currently a party in a civil lawsuit? Yes No

Are there any pending administrative, judicial, or professional authority actions?

Yes No

Been contacted by any court, state, or federal administrative or regulatory agency or professional association or the Better Business bureau regarding allegations of adversarial actions or complaints?

Yes No

Been subject of a court sanction/order, a complaint to the State Attorney General or the Better Business Bureau, or been contacted by any prosecutorial, judicial, or administrative agency or association regarding business practices?

Yes No

SECTION VIII: BUSINESS INFORMATION. Except for a few questions in this section designated for “traditional format schools only” each question must be answered by ALL business entity applicants, including alternative delivery method (ADM) applicants. ADM format businesses must also complete the “Addendum to Business Entity Certification Application for Alternative Delivery Method (ADM) Format” form. Also, for any questions in this section requiring a “yes” or “no” answer, you must attach a complete written explanation for any “no” answer.

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1. List (a) the states, provinces or countries your organization is licensed or certified to do business as a defensive driving school and (b) the telephone number of each licensing entity listed.

2. How long has your organization been instructing defensive driving courses in these states, provinces, or countries?

3. List branch offices or other entities that will perform, or assist in performing the work of the organization associated with offering defensive driving courses for court diversion, including addresses, contacts, and the functions to be performed:

4. Provide a copy of all third party contracts regarding any operational or financial proceedings with the application. The applicant shall not contract with a third party to complete or issue completion certificates. Incidental operations such as telephone, copying, or Internet services are not subject to

this requirement. [See ACJA §7-205(E)(1)(g)].

5. If applicable, attach a list of any other individuals (not included in #4) who may derive a profit (other than rental income or instructor fees at fair and reasonable market rates) from the operation of this business.

6. Attach an original Certificate of Insurance which names the State of Arizona and the Arizona Supreme Court as additional insured parties. [Note: Coverage must meet the requirements of ACJA § 7-205(E) (1) (h) (1) through (h) (4)].

7. As directed on the first page of this application form, applicants must attach articles of incorporation and letters of good standing from the Arizona Corporation Commission or the Secretary of State. However, if your organization is a non-Arizona company, attach the same documents obtained from comparable entities in the state where the business is located [See ACJA § 7-205(E)(1)(j)].

8. File a defensive driving course curriculum only by electronic means. Pursuant to A.R.S.§ 28-3395, the time allowed for the course, including testing, reviewing and grading of any test, or completion of an evaluation form shall not exceed 270 minutes nor be less than 240 minutes. [See ACJA § 7- 205(E)(1)k)].

9. Traditional format schools only: Attach a list of films and other visual presentations which will be used including (1) title of each, (2) type of media, (3) source, (4) length, and (5) a list which denotes the segment of the class in which each will be utilized [See ACJA § 7- 205(E)(1)k) and (r)(3)].

10. Attach a detailed description of the organization's operational and financial procedures, including how your business’s procedures and records will conform to generally accepted accounting principles and the minimum accounting standards adopted by the supreme court [See ACJA §§ 7-205(F)(12) and (27)].

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11. Attach an outline of the instructor training seminar your business has developed and include a current copy of an Instructor's Training Manual and a training evaluation form used [See ACJA § 7-205(E)(1)(q)].

12. Attach your business’s refund policy and explain how you will disclose this policy to each student before they start your course [See ACJA §§ 7-205(E)(1)(v) and 7-205(F)(30)].

13. Describe collection and disbursement of fees and the reports generated for compliance with requirements of certification criteria [See ACJA §§ 7-205(E)(1)(n) and 7-205(F)(27) through (29)].

14. Traditional format schools only: Describe in detail the kinds of information you will provide to the Supreme Court in future class schedules and the method by which you will provide it, meeting the required deadlines [See ACJA § 7-205(F)(5)(g) and (F)(23)].

15. Traditional format schools only: Provide a list of sites where the defensive driving course will be made available [See ACJA § 7-205(F)(5)(g)].

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16. Describe how your business will comply with requirements for accessing the defensive driving database correctly and accurately [See ACJA § 7-205(F)(25)(b)(1) through(5)].

17. Is your course and business in full compliance with all Federal laws pertaining to the Americans With Disabilities Act (ADA) [See ACJA § 7-205(F)(25)(c)(9)]

Yes No (if “No” is marked, you must explain)

18. Explain the methods of your eligibility process for ensuring a student and his/her citation is eligible to attend for diversion purposes [See ACJA § 7-205(F)(25)(d)(1)(a) and (b)].

19. Traditional format schools only: Attach the procedures to be used to ensure accurate in-person identification of students prior to class [See ACJA § 7-205(F)(25)(4)(a)].

20. Describe your policies and procedures for explaining to each individual enrolling in a defensive driving course the provisions and implications of signing an affirmation of eligibility and how/when the student will read and sign this affirmation [See ACJA § 7-205(F)(25)(4)(d)].

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21. Traditional format schools only: Describe how your business will ensure the number of students will never exceed 60 attendees per class [See ACJA § 7-205(F)(25)(8)].

22. Attach a copy of your student evaluation form [See ACJA § 7-205(F)(25)(12)].

23. For traditional classroom schools only: Explain your procedures for handling out-of-state course attendance and completion [See ACJA § 7-205(F)(26)].

24. Describe policies and procedures for records retention [See ACJA § 7-205(F)(27)(e)].

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25. Describe policies and procedures for error correction for state fee and completion records [See ACJA §§ 7-205(F)(27)(i)].

26. Explain how and when you will notify the Defensive Driving Tracking System of students’ registration, fee payments and completions [See ACJA § 7-205(F)(25)(a) and (b)].

27. Attach proof of the rights which have been obtained to use all audio visual materials used [See ACJA § 7-205(E)(1)(r)] and (J)(1)(a).

28. Attach a listing and samples of any handouts or other materials available to the attendees and disclose how you have exercised extreme care and diligence to ensure all materials to be used in the instruction of a defensive driving course, whether in a classroom or ADM format, are in the public domain and not copied without the appropriate written permission [See ACJA § 7-205(E)(1)(r) and (J)(1)(a)].

29. Explain procedures developed to ensure confidentiality of student records and the Defensive Driving Tracking System (both physically and electronically) [See ACJA § 7-205(F)(8) and (J)(1)(b)(1)

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30. Describe your policies and procedures to ensure no inducements are offered to students or potential students for choosing the business’s course other than for the lawful diversion of an eligible traffic citation [see ACJA § 7-205(J)(1)(e)].

31. Provide by electronic means, either on disk or URL, a mock up of your school’s web site that will be used for presentation of your Arizona course to the public and method of registration on the site for prospective students.

32. Attach the correct certification fee using a money order or cashier’s check only, and make payable to “Arizona Supreme Court” [See #7 on Page 19 for applicable fees. Also, refer to ACJA § 7-205(K) for applicable fee schedule].

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SECTION IX: ACKNOWLEDGMENT OF DESIGNATED PRINCIPAL. Signature and notarization required. I, _______________________________, the designated principal pursuant to Judicial Administration Code §§ 7-201 and 7-205, agree to ensure that:

a) I will prepare and submit, WITH THIS APPLICATION, a list of all instructors or applicants for certification and staff members requiring access and training for the defensive driving database.

b) I will actively and directly supervise all certified instructors, instructors in training and staff who have

access to the defensive driving database to ensure compliance to all Arizona Statutes and ACJA §§ 7-201 and 7-205.

c) I will file with Division Staff, by December 1

st of each year, a list of all certified instructors and staff

of the school who have access to the defensive driving database, as of October 31st of that year.

d) I will notify Division Staff within seven days if a certified instructor or staff member with access to the

defensive driving database leaves the employment of the school.

e) I will represent the school (business) entity, at the discretion of the entity, in any proceeding under this Arizona statutes, and ACJA §§ 7-201 and 7-205..

f) I will notify the Division Staff within 30 days if I am no longer in a position to continue serving as the

designated principal for the business entity.

g) I will make all business entity members and certified instructors aware that they are bound by the Code of Conduct for Defensive Driving as promulgated by the Arizona State Supreme Court.

h) I will file, in writing, with the Division Staff, a notice of any changes in business entity members listed in

Section II of this application within 30 days of any change.

i) I have read and reviewed the Arizona Code of Judicial Administration §§ 7-201 and 7-205 and understand and agree to abide by and uphold these sections.

___________________________________________ Signature of Designated Principal

Single Acknowledgment THE STATE OF __________________, COUNTY OF ________________________________ Before me, the undersigned authority, on this day personally appeared ________________________________, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that he/she executed the same for the purposes expressed, and affirmed that the facts detailed are true. Given under my hand and seal of office on this __________day of ___________________, 20_________. _________________________________________ Notary Public, State of Arizona ______________________________________ ________________________________ Notary’s Name Printed My Commission Expires

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SECTION X-a: CONFLICT OF INTEREST STATEMENT. Pursuant to Arizona Code of Judicial Administration (ACJA) § 7-205(E)(1), I certify _________________________________________________, a business entity seeking certification as, or operation of, a school to provide defensive driving courses as court diversion programs in the state of Arizona, does not currently have or employ, nor will it permit in the future, owners, officers, partners, or employees who are directly involved in the operation of defensive driving schools providing court diversion programs in the state of Arizona, and who, pursuant to Arizona Code of Judicial Administration § 7-205(E)(3)(b), are:

(1) Employees of a public agency, which has within the regular scope of duties the power to cite individuals for minor moving violations, to influence the resolution of citations for minor traffic violations, or otherwise control, advise, solicit, or order the attendance, or potential attendance of individuals in a school. This limitation on certification or operation of a school by public agencies or employees of public agencies does not preclude law enforcement officers from acting solely as employed or contracted instructors for schools provided the provisions of subsection (E)(2)(j) are met;

(2) Employees of a public agency which or who are in a position to derive a profit or fund the

agency’s or person’s own activities from the use of its facilities or employees in the presentation of a defensive driving course;

(3) Individuals employed by a school, either for pay or as a volunteer, of any employee of a

public agency who has within the regular scope of the employee’s duties the power or ability to control, advise, solicit, or order the attendance of individuals in a school, or who is in a position to derive a profit or fund the public agency's activities from the use of the public agency's facilities and employees to further the presentation of a school's defensive driving course;

(4) Employees who may receive from or offer incentives to a court employee, either directly or

indirectly, in order to enroll students in a school or for selection of a specific school as a primary provider;

(5) Employed as a volunteer or paid employee, or compensation of any court officer or

employee, to operate, instruct or provide any service to a school; or

(6) Involved with any other apparent or actual conflict of interest.

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SECTION X-b: INDEMNIFICATION STATEMENT. Pursuant to ACJA § 7-205(E)(1), I certify the business entity named in this application agrees to indemnify, defend, and hold harmless the Arizona Supreme Court and any other court contracting or otherwise doing business with the applicant from any and all claims, demands, suits, actions, proceedings, loss, cost and damages of every kind and description. This includes any reasonable attorney's fees and or litigation expenses which may be brought or made against or incurred by the court on account of loss or damage to any property or for injuries to or death of any person, to the extent caused by, arising out of, or contributed to, in whole or in part, by reason of the operation of the defensive driving school, or arising out of worker's compensation claims, unemployment compensation claims, or unemployment disability compensation claims of employees of the defensive driving school or claims under similar such laws or obligations.

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SECTION X-c: AUTHORIZATION AND RELEASE. Signature and notarization required. Having filed this application, I hereby consent to having an investigation made of the businesses character, professional reputation, and fitness for Defensive Driving certification. I agree to give any further information which may be required in reference to the past record of the business. I also authorize and request every person, firm, company, corporation, governmental agency, court, association, or institution having control of any documents, records, and other information including documents, records, charges or complaints filed against the business, formal or informal, pending or closed, or any other pertinent data, and to permit the Arizona Supreme Court, or any of its agents or representatives to inspect and make copies of such documents, records, and other information. I release, discharge, and exonerate the Arizona Supreme Court, its agents and representatives, the State of Arizona, and any person furnishing information pursuant to this Authorization and Release from all liability which may arise from the investigation made by the Arizona Supreme Court. I acknowledge that I have read this application form and that all statements are true and complete to the best of our knowledge and belief and that this Authorization and Release is freely given. I understand willful omission or misrepresentation of any fact required to be disclosed in this application, or any accompanying statement, is grounds for refusing to issue or renew a certificate or for revoking or suspending a certificate. I also declare under penalty of perjury under the laws of the State of Arizona that the foregoing is true and correct.

___________________________________________________ Full Signature of Business Entity Owner or

Designated Principal Who Has Contracting Authority

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AFFIDAVIT OF VERIFICATION - BUSINESS ENTITY ACKNOWLEDGMENT

THE STATE OF __________________, COUNTY OF _________________________________ Being duly sworn, I, ______________________ on behalf of ___________________________ , depose and say that I have read the foregoing, and each statement and answer made, and this Authorization and Release, and under penalty of perjury, swear that all such answers, statements and data attached to this application are true and correct. Willful misrepresentation of any fact required to be disclosed in any application, or accompanying statement, is grounds for refusing to issue or renew certification, or for revoking or suspending a certificate. Before me, the undersigned authority, on this day personally appeared: ______________________________________ of ___________________________________________ , Title Exact Business Entity Legal Name a corporation, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that he/she executed the same for the purpose expressed, in the capacity stated and as the act and deed of said corporation, and affirmed that the facts detailed are true. Given under my hand and seal of office on this ____________ day of ___________________, 20______. _________________________________________ Notary Public, State of Arizona _______________________________________ ___________________________ Notary’s Name Printed My Commission Expires

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SECTION XI. ADDITIONAL INSTRUCTIONS AND INFORMATION 1. Instructions: Carefully read all instructions prior to completing the application. Incomplete application

submissions will result in the rejection of the application. To obtain additional assistance, e-mail, or call Division Staff at (602) 452-3987, or visit the Arizona Judicial Department Web site www.supreme.state.az.us/drive.

2. Complete the relevant form-fillable documents online. If the document requires completion by hand,

use only black ink. Pages 14 and 18 must be notarized. Pursuant to Arizona Code of Judicial Administration (ACJA) §§ 7-201 and 7-205, incomplete applications will not be accepted. Pursuant to ACJA § 7-201(E)(3)(b), you have ninety (90) days to complete the certification process. After ninety days, you will be required to submit a new application and new fees.

3. Provide proof of citizenship or legal status for every owner, principal, officer, director or shareholders

listed in Section II. 4. Business Entity Documentation. As noted on Page 1 of the application form, all Corporations and

Limited Liability Companies making application for certification MUST submit, along with the application, a copy of the entity’s Articles of Incorporation/Organization AND a current certificate of Good Standing from the Corporation Commission.

5. Certified Defensive Driving Instructors. Page 3 of this application must include a list of ALL certified

defensive driving instructors employed by the business entity. Add additional pages if necessary. 6. Designated Principal. Pursuant to Arizona Code of Judicial Administration § 7-205(E)(1)(h), a

designated principal for the business entity must be an individual with whom Division Staff may communicate on any procedural or operational concern or problem and who will have certain responsibilities pursuant to subsection F, including contacting authority within the State of Arizona. Notarization of the Designated Principal’s signature is required on page 14.

7. Fees. All applicable NON-REFUNDABLE fees shall accompany this application and be made payable

to the Arizona Supreme Court. Initial application fees are $4,000.00. 8. Assumed Name (or D.B.A.) And Trade Names. While conducting business as a defensive driving

school, a certificate holder shall use the name as shown on the certificate and shall not transact business in this state under an assumed name or under any designation, name or style, corporate or otherwise, other than the real name of the business entity unless the business entity files with the Division Staff a certificate setting forth the name under which business will be transacted.

9. Conflict of Interest and Indemnification Statements and the Authorization and Release form. The business entity owner or Designated Principal’s signature and notary verification for these statements are required on Page 17. Note: Any Designated Principal must have contracting authority.

10. Applicant Background Information. If you answered “YES” to any question in Section V of this

application, you must (a) send a list of all incidents and complete a written explanation of the events for each, this includes incidents which may be pending and/or in litigation; and, (b)send any and all documentation which shows where the violation, finding, or conviction occurred, the nature and details of the case, case disposition, court, case number, and any other relevant information. Attach as many additional sheets as is necessary to fully explain each “yes” answer.

11. Submission. Send your completed application, required documents, related attachments, and fees to:

Defensive Driving Certification

Certification and Licensing Division Arizona Supreme Court

1501 W. Washington, Suite #104 Phoenix, AZ 85007

APPLICATION FOR ADM FORMAT FOR CURRENTLY CERTIFIED BUSINESS ENTITIES

Arizona Supreme Court 05/10/2012 Certification & Licensing Division Defensive Driving Program

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APPLICATION FOR ALTERNATIVE DELIVERY METHOD (ADM) FORMAT

FOR CURRENTLY CERTIFIED BUSINESS ENTITIES

INSTRUCTIONS:

1. CAREFULLY READ “ADDITIONAL INSTRUCTIONS AND INFORMATION” ON PAGE 8.

2. Application must be completed online, printed and submitted to the Arizona Supreme Court. Any form that requires completion by hand must be done in black ink.

3. Answer all questions and submit all documentation requested on this form. If any section of this application does not apply, indicate by “N/A.”

4. For questions requiring a “Yes” or “No” response, you must fully explain any “No” answers.

SECTION I: BUSINESS/DESIGNATED PRINCIPAL INFORMATION. School Name:

AOC Certification number:

Name of: Owner *Designated Principal (see

page 8)

Date of Application:

Business Address: (Street Address) (City) (State) (Zip) Business Phone Number: Business Fax:

Business E-mail Address: Principal’s Social Security Number

SECTION II. ADM FORMAT REQUIREMENTS. You must respond with detailed answers to each item/question listed in this application. Incomplete or inaccurate responses may delay or processing or disqualify your application.

1. File a defensive driving course curriculum only by electronic means. The course must meet curriculum and course length requirements pursuant to ACJA § 7-205(E)(1)(K).

2a. Is any portion of the ADM format course the original or previous property of another business entity? Yes No



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2b. If the answer to #2 was “yes,” provide the name of the business entity who owns/owned the course and attach a copy of documentation which shows your business has a legal right to use and/or offer the ADM course or any portion of the course as your own.

3. Describe how you will notify each prospective enrollee of: (a) all requirements, policies and procedures for participation in the course, including hardware/software requirements; (b) cost and acceptable payment methods; (c) privacy/confidentiality policies; (d) requirements for successful completion of the course and the time frames for the completion of the course; (e) the passing rates for the course participation questions; (f) the penalties for fraud.

4. How will you ensure the students indicate acknowledgment and acceptance of all terms and conditions pertaining to enrolling, completing and passing the examination for your ADM course?

5. Explain how you will secure payment of all fees and have all required documents physically “in hand” prior to the student beginning the ADM Course.

6. Describe how validation of identification, citation, and court orders will be handled prior to a student beginning the on-line course.



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7. Explain your procedures for how students with questions will be able to contact the school; include hours of operation, how materials encourage students to call with questions, and an explanation of how questions will be addressed.

8. Explain how students will receive technical assistance and include the time frame for a response.

9. Explain how students will be notified when technical or other difficulties are encountered.

10. Attach a statement that acknowledges how maintenance functions will be performed after scheduled hours and that outages for repairs will not exceed 24 hours.

11. Describe the system that will be used for tracking a student’s progress through your course and how an electronic footprint of that progress will be produced at the request of the AOC.

12. Attach the 25 course participation questions, and describe if they will be administered throughout or at the conclusion of the course.



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13. Explain (a) procedures for grading tests, (b) the requirements for achieving the passing score (80%), and (c) how failures will be handled.

14. Explain procedures for students who are caught cheating or who fail the final exam.

15. Explain procedures for issuing completion certificates or receipts, and provide copies. Include what safeguards are in place to avoid issuing completion certificates to students who either fail testing or fail to complete the course. Also, include procedures for referring failed students to the proper court or a classroom school.



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16. Describe how security of physical and electronic information will be achieved, including the confidentiality of the Defensive Driving Tracking System (DDTS).

17. Describe procedures in place to quickly address problems that affect quality of the program and responsiveness to the needs of the public and courts.

18. Describe retention of records, both physical and electronic.

19. Describe how the school will ensure no commercial advertisements are included in the course.

20. Attach your business’s refund policy and explain how you will disclose this policy to each student before they start your course.

21. Is your course in full compliance with all Federal laws pertaining to the Americans With Disabilities Act (ADA) [See ACJA § 7-205(F)(25)(c)(9)?

Yes No (if “No” is marked, you must explain)

22. Attach a listing and samples of any handouts or other materials available to the attendees and disclose how you have exercised extreme care and diligence to ensure all materials to be used in the instruction of a defensive driving course in an ADM format, are in the public domain and not copied without the appropriate written permission [See ACJA § 7-205(J)(1)(a)].



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SECTION III: AUTHORIZATION AND RELEASE. Signature and notarization required.

Having filed this application, I hereby release, discharge, and exonerate the Defensive Driving Program, its agents and representatives, the State of Arizona, and any person furnishing information pursuant to this Authorization and Release from all liability which may arise from the investigation made by the Defensive Driving Program.

I consent to having an investigation made concerning the company’s business practices, of the moral character, professional reputation, and fitness for certification under program rules of all officers, directors, partners, members, trustees, managers or principals. I agree to give any further information which may be required in reference to my past or current record.

I also authorize and request every person, firm, company, corporation, governmental agency, court, association, or institution having control of any documents, records, and other information including documents, records, charges or complaints filed against the business, formal or informal, pending or closed, or any other pertinent data, and to permit the Arizona Supreme Court, or any of its agents or representatives to inspect and make copies of such documents, records, and other information.

I understand willful omission or misrepresentation of any fact required to be disclosed in this application, or any accompanying statement, is grounds for refusing to issue or renew a certificate or for revoking or suspending a certificate. I acknowledge that I have read this application form and that all statements are true and complete to the best of our knowledge and belief and that this Authorization and Release is freely given. I certify that the information included above and/or attached to this application addendum is true and correct.

___________________________________________________ Full Signature of Business Entity Owner or

Designated Principal Who Holds Contracting Authority



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AFFIDAVIT OF VERIFICATION - BUSINESS ENTITY ACKNOWLEDGMENT THE STATE OF __________________, COUNTY OF ________________________________________ Being duly sworn, I, ______________________ on behalf of ___________________________ , depose and say that I have read the foregoing, and each statement and answer made, together with the Authorization and Release and under penalty of perjury, swear that all such answers, statements and data attached to this application are true and correct. Willful misrepresentation of any fact required to be disclosed in any application, or accompanying statement, is grounds for refusing to issue or renew certification, or for revoking or suspending a certificate. Before me, the undersigned authority, on this day personally appeared: ______________________________________ of ___________________________________________, Title Exact Business Entity Legal Name a corporation, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that he/she executed the same for the purpose expressed, in the capacity stated and as the act and deed of said corporation, and affirmed that the facts detailed are true. Given under my hand and seal of office on this ________ day of _______________ , 20______. _________________________________________ Notary Public, State of Arizona _________________________________________ ________________________________ Notary’s Name Printed My Commission Expires



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ADDITIONAL INSTRUCTIONS AND INFORMATION

Instructions. Carefully read all instructions prior to completing this application form.

o This form should only be used by business entities which currently hold certification as an Arizona Defensive Driving School and seeks to offer, when approved, an alternative delivery method format course in addition to the traditional classroom format course which is currently being offered by this school.

o If the business entity is not already certified to instruct traditional classroom courses, you must complete and file an “Application for Initial Certification as a Business Entity” and an “Addendum to Business Entity Certification Application for Alternative Delivery Method (ADM) Format.”

*Designated Principal. Pursuant to ACJA § 7-205(E)(1)(i), a school’s Designated

Principal must be someone within the State of Arizona who holds contracting authority for the school, with whom division staff can immediately make contact concerning any process or procedure of the school or court operation.

Completion. Incomplete submissions will result in the rejection of the application or

addendum. To obtain additional assistance, call the Defensive Driving Program Specialist at (602) 452-3985, or e-mail: [email protected]

Additional modality fee. Any certified classroom school adding an additional

modality (alternative delivery) must pay an application fee in the amount of $2000, per ACJA §7-205 (K)(5)(f).

Submission. Please submit this completed and notarized form, plus all backup or

additional documentation required in this form and a check in the amount of $2000 to:

Certification and Licensing Division

Compliance Unit Arizona Supreme Court

1501 W. Washington, Suite #104 Phoenix, AZ 85007

Y:\COMPLIANCE\CERTIFICATION-ADMISSIONS\DEFENSIVE DRIVING\PACKET FOR NEW

SCHOOLS\Application for ADM Format for Currently Certified Schools 03.07.12.doc

mailto:[email protected]

Arizona Supreme Court Version 5.2

Certification and Licensing Division Rev. 05.10.12

Defensive Driving Program

1



INITIAL APPLICATION FOR INSTRUCTOR CERTIFICATION All boxes and spaces of this application must be completed online and submitted to the Arizona Supreme Court. If a form requires completion by hand, it must be completed in black ink. Any willful omission or misrepresentation of any fact to be disclosed in this application or any accompanying statement or document is grounds for refusing to issue certification. Page 4 of the application form must be signed and notarized. SECTION I. Applicant Information

School Name School Number

First Name Middle Name

(Legal) Last Name

Nickname

Arizona Driver’s License Number

Expiration

Date of Birth E-mail address Social Security Number

Home Address

(Street) ______________________________________________________________________

(City) _________________________________________ (State) _______________

(County) _______________________________________ (Zip) ________________

Applicant’s Business Address (not school address)

(Street) ______________________________________________________________________

(City)__________________________________________ (State) ________________

(County) _______________________________________ (Zip) __________________

Home Phone Number ( )

Business Phone Number ( )

HS diploma G.E.D. Highest College Degree Completed:______________________

Important: applicant must provide copy of HS diploma, G.E.D., or diploma from highest college degree completed.




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Yes No The applicant must answer “yes” or “no” to the following four questions and

provide backup documentation as required:

1. Are you a legal resident or citizen of the United States? If “yes,” you must attach

proof. Acceptable documents are listed on page 6 of this application. The documents

you have attached to this application must be one of the following two options:

ONE document from List A (see page 6); or

ONE document from List B plus ONE document from List C (see page 6).

2. Are you awaiting trial for any misdemeanor (other than a traffic offense) in the state of

Arizona, or a like offense in any other state or foreign country? (If yes, you must

provide an explanation on a separate sheet and attach to this application.)

3. Are you an active law enforcement officer with authority to issue traffic citations? (If

yes, you must attach the “Waiver for Law Enforcement Officer to Serve as a

Defensive Driving Instructor for an Arizona Certified School” form signed by the

Presiding Judge of the Superior Court in the county where the instructor’s

defensive driving school is located.)

4. Have you been previously employed as a defensive driving instructor? (If yes, list the

school(s) where you were employed and the dates of employment.)

SECTION II: Background Information. If the answer to any of the following questions is “Yes”,

indicate date of conviction or finding, nature and details of the case, including the case disposition,

location, court and case number (attach additional sheets, if necessary).

Has the applicant:

Ever been found guilty of any felony or misdemeanor?

(Note: the fact that the applicant entered into a plea bargain or pled “no contest”, or

that the conviction has been vacated, pardoned, expunged, dismissed, or appealed, or

that the civil rights have been restored does not mean that the question can be

answered no. If the answer is yes, give details of the offense, and explain. Do not

answer yes or give details if the offenses are only minor civil traffic violations.)

Yes No

Ever been convicted of, or found responsible for, any traffic offense(s) in Arizona or

any other state or foreign country during the past 5 years. Yes No

Ever had a license to drive in Arizona or in any other state or foreign country refused,

canceled, suspended, revoked, issued conditionally or on a probationary basis? Yes No

Committed material misrepresentation, omission, fraud, dishonesty, or corruption in

applying for a certificate or on a certificate examination in this state or any other

state?

Yes No

Committed any act constituting material misrepresentation, omission, fraud,

dishonesty or corruption in business or financial matters? Yes No

Had conduct showing incompetence or a source of injury and loss to the public? Yes No

Been convicted by final judgment of a felony, regardless of whether civil rights have

been restored? Yes No

Been convicted by final judgment of a misdemeanor, regardless of whether civil

rights have been restored? Yes No

Had a professional or occupational license or certificate denied, revoked, suspended

or disciplinary action taken? Yes No




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Had a professional or occupational license or certificate censured, placed on

probation, or disciplinary action taken? Yes No

Been terminated, suspended, placed on probation, or other disciplinary action taken in

past or present employment? Yes No

Been found civilly liable in an action involving misrepresentation, material omission,

fraud, misappropriation, theft or conversion? Yes No

Currently on probation or parole? Yes No

Violated any decision, order, or rule issued by a professional regulatory entity? Yes No

Violated any order of a court, judicial officer, administrative tribunal, or the Board? Yes No

Made a false or misleading statement or verification in support of an application for a

certificate filed by another person? Yes No

Made a false or misleading oral or written statement to division staff or the Board? Yes No

Failed to disclose information on the certification application which was subsequently

revealed through a background check? Yes No

Failed to respond or furnish information to division staff or the Board when the

information is legally requested and is in your control or is reasonably available to

you and pertains to certification or investigative inquiries?

Yes No

Had a record of conduct constituting or investigative inquiries; or fraud on the part of

an employee, board member, or the business? Yes No

Been or currently a party in a civil lawsuit? Yes No

Have any pending administrative, judicial, or professional authority actions? Yes No

SECTION III. Additional Application Requirements:

1. See page 6 for instructions on how to provide proof of citizenship/residency [ACJA § 7-205(E)(2)(c).

2. A color passport-size photo (2” x 2”) of the applicant’s head, neck, and shoulders only, taken in the

last two years and which clearly identifies the applicant, must be attached on Page 5 in the designated

space. An application submitted without a photograph is deficient [ACJA § 7-201(E)(1)(c)].

3. Applicant must be at least 21 years old and pass a certification examination testing his/her knowledge,

skills and abilities as an instructor [ACJA § 7-205(E)(2)(e)].

4. Applicant must attach a certified 60-month motor vehicle record to the application [ACJA § 7-

205(E)(2)(f)]. (Note: if the motor vehicle record does not have a 60-month history with the Arizona

Motor Vehicle Division, then a similar record from another jurisdiction must be provided for the most

recent 60 months.)

5. Any applicant currently serving as an active law enforcement officer with authority to issue traffic

citations must obtain and attach a waiver approved by the Presiding Judge of the Superior Court in the

county where the instructor’s defensive driving school is located [ACJA § 7-205(E)(2)(j)].

SECTION IV. Applicant’s Photo

One 2” x 2” color passport-size photo must be clipped to the

designated space at left on this page of the application form.

Please use a paper clip to attach the photo; do no use staples

or glue.

Also, prior to attaching, please write your name on the back

of the photo.




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SECTION V. Authorization, Release, Oath and Affirmation

Having filed this application, I hereby consent to having an investigation made of my moral character,

professional reputation, and fitness for defensive driving instructor certification. I agree to give any further

information which may be required in reference to my past or current record.

I authorize and request every person, firm, company, corporation, governmental agency, court, association, or

institution having control of any documents, records, and other information including documents, records,

charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent data, to

permit the Defensive Driving Program, or any of its agents or representatives to inspect and make copies of

such documents, records, and other information.

I release, discharge, and exonerate the Defensive Driving Program, all agents and representatives, the State of

Arizona, and any person furnishing information pursuant to this Authorization and Release from all liability

which may arise from the investigation made by the Defensive Driving Program, all agents and

representatives.

I swear or affirm that I am not currently employed as a volunteer or paid employee of any court in any capacity

including as a probation officer or employee. I understand willful omission or misrepresentation of any fact

required to be disclosed in this application or any accompanying statement is grounds for refusing to issue or

renew a certificate or for suspending or revoking a certificate.

Being duly sworn and under oath or affirmation, I acknowledge that I have read this application form and that all

statements are true and complete to the best of my knowledge and belief and that my Authorization and Release are

freely given. I acknowledge that I have read and understand all supreme court requirements for the Defensive

Driving Program as stated in Sections 7-201 and 7-205 of the Arizona Code of Judicial Administration and I

swear or affirm that all Defensive Driving Program classes conducted by me will comply with all

requirements. I acknowledge that failure to comply as required may result in suspension or revocation of my

certification. I agree the Arizona Supreme Court may obtain, release and discuss all records concerning my

prior or current defensive driving program certification from, to or with any certified defensive driving school

or applicant school.

_____________________________________________

Full Signature of Applicant

AFFIDAVIT OF VERIFICATION

THE STATE OF ARIZONA, COUNTY OF ________________________________

Before me, the undersigned authority, on this day personally appeared _______________________,

known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged

to me that he/she executed the same for the purposes expressed, and affirmed that the facts detailed are

true.

Given under my hand and seal of office on this ________ day of ____________________, 20______.

_________________________________________

Notary Public, State of Arizona

__________________________________________ ___________________________________

Notary’s Name Printed My Commission Expires




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LIST OF ACCEPTABLE RESIDENCY/CITIZENSHIP DOCUMENTS To respond correctly to Question #1 on Page 2 of this application, you must provide copies of:

One (1) document from List A

OR Two (2) documents: one from List B and one from List C

List A (documents which establish both identity and employment eligibility)

1. U. S. Passport (unexpired or expired). 2. Certificate of United States Citizenship [U.S.

Immigration and Naturalization Services (INS) Form N-560 or N-561].

3. Certificate of Naturalization (INS Form N-550 or N-570).

4. Unexpired foreign passport which: a. Contains an unexpired stamp which

reads “Processed for I-551. Temporary Evidence of Lawful Admission for permanent residence. Valid until ________. Employment authorized;” or

b. Has attached to it a Form I-94 bearing the same name as the passport and containing an employment authorization stamp, so long as the period of endorsement has not yet expired, and the proposed employment is not in conflict with any restrictions or limitations identified on the Form I-94.

NOTE: For more detailed information concerning the Form I-94, see page 23 of the “Handbook for Employers (M-274).”

5. Alien Registration Receipt Card (INS Form I-151 or I-551) provided it contains a photograph of the bearer.

6. Unexpired Temporary Resident Card (INS Form I-688).

7. Unexpired Employment Authorization Card (INS Form I-688A).

8. Unexpired reentry permit (INS Form I-327). 9. Unexpired Refugee Travel document (INS

Form I-571). 10. Unexpired Employment Authorization

Document issued by the INS which contains a photograph (INS Form I-688B).

List B (documents which establish identity only)

1. Driver license or ID card issued by a state or outlying possession of the United States (provided it contains a photograph or information such as name, date of birth, gender, height, eye color and address).

2. ID card issued by federal, state or local government agencies or entities (provided it contains a photograph or information such as name, date of birth, gender, height, eye color and address).

3. School ID card with photograph. 4. Voter’s registration card. 5. U. S. Military card or draft record. 6. Military dependent’s ID card. 7. U. S. Coast Guard Merchant Mariner Card. 8. Native American tribal document. 9. Driver license issued by a Canadian

government authority.

List C (documents which establish employment eligibility only)

1. U. S. social security card issued by the Social Security Administration (other than a card which has printed on its face “NOT VALID FOR EMPLOYMENT”). NOTE: This must be a card issued by the Social Security Administration; a facsimile (such as a metal or plastic reproduction) is not an acceptable document.

2. Certification of Birth Abroad issued by the

Department of State (Form FS-545 or Form DS-1350).

3. Original of certified copy of a birth certificate issued by a state, county, municipal authority or outlying possession of the United States bearing an official seal.

4. Native American tribal document. 5. U. S. Citizen ID Card (Form I-197). 6. ID Card for use of Resident Citizen in the

United States (Form I-179). 7. Unexpired employment authorization

document issued by the INS.

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274) provided by the Department of Homeland Security, U. S. Citizenship and Immigration Services at http://www.uscis.gov/files/nativedocuments/m-274.pdf

http://www.uscis.gov/files/nativedocuments/m-274.pdf




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Application Instructions and Additional Information

1. INSTRUCTIONS. Carefully read all instructions. To obtain additional assistance, email

[email protected] or visit the Arizona Judicial Department Website at

http://www.supreme.state.az.us./drive/certificationInfo.htm

2. EXAMINATION REQUIREMENT. In order to be eligible to apply for certification, you

must have successfully participated in the Defensive Driving Examination. For instruction

on how to register for the examination and to obtain a Defensive Driving Examination

Candidate Study Guide, please visit the above referenced website.

3. COMPLETION. Complete form-fillable application online. Incomplete applications may

result in the rejection of the application.

4. BACKGROUND INFORMATION. If you answered “YES” to any question in the

Background Section of this application, you are required to submit a SIGNED and

NOTARIZED statement describing in detail all incidents including: (1) names of all parties

involved, (2) dates and locations, (3) the names and localities of any courts and/or

administrative agencies involved, (4) the disposition of each matter, and (5) whether the

conviction, plea or finding was for a felony, misdemeanor, or open-ended charge.

5. AUTHORIZATION, RELEASE, OATH, AND AFFIRMATION. Applicant signature

and notary verification are required.

6. SUBMISSION. Please print out and submit your completed application, and related

attachments to:

Arizona Supreme Court

Defensive Driving

1501 West Washington, Suite 104

Phoenix, Arizona 85007-3231

mailto:[email protected]

http://www.supreme.state.az.us./drive/certificationInfo.htm

cc: □ Arizona Supreme Court □ Presiding Judge of Superior Court □ Law Enforcement Officer

□ Instructor’s Defensive Driving School Employer

Y:/ Compliance\Certification-Admissions\Defensive Driving\Packet for New Schools\WAIVER for Law Enforcement Officer 11.06


Administrative Office of the Courts

Waiver for Law Enforcement Officer to Serve as a Defensive Driving Instructor

for an Arizona Certified School

Pursuant to Arizona Code of Judicial Administration § 7-205(E)(2)(g),

I, ___________________________________________________, a law enforcement officer for

__________________________________________________ (name of agency), in the jurisdiction of the

□ City □ County of ______________________________________, in Arizona, hereby request a waiver

by the Presiding Judge of the Superior Court in ________________________________ County in order to

serve as a defensive driving course instructor for ______________________________________________,

an Arizona certified defensive driving school which serves the courts in this county listed on the attached

document. My current duties as a law enforcement officer involve issuing traffic citations.

________________________________________ __________________________________

(Officer’s signature) (Date)

________________________________________ __________________________________

(Job Title) (Law Enforcement Agency)

(Information below this line to be completed by Presiding Judge of the Superior Court)

Special conditions for granted waiver:

□ None □ Ordered by the Presiding Judge, as follows:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Waiver granted by:

______________________________________ _________________________ _____________________

(Presiding Judge’s signature) (County) (Date)

defensive driving certification application for initial

Documents