Arizona Chapter National Safety Council (ACNSC) is contracted to administer the ADOT-MVD Traffic Survival School (TSS) program.

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1 Print or type; must be legible, complete and correct If not applicable, enter NA If additional space is needed, attach separate sheet All fees may be paid by check or money order, payable to ACNSC. Application is hereby made for a license to engage in Traffic Survival School Training activities. A $ fee is required. Business Type Sole Proprietorship 1 General Partnership 1 Corporation 2 LLC 2 LLP 2 Government/Political Subdivision Other: 1 Attach Authorized Presence Documentation form 2 Attach copy of Articles of Incorporation or Organization as filed with the Arizona Corporation Commission Company Name Employer Identification Number Doing Business As (DBA) Mailing Address City State Zip Established Business Address (where instruction will be provided) City State Zip List all additional branch locations on the Professional Driver Services Change Request form and attach. Principal Business Address (administrative/operation headquarters, where records will be secured) Address (if different from Mailing Address) City State Zip Office Days and Hours M: Tu: W: Th: F: Sa: Su: Business Manager Business Manager Name (first, middle, last suffix) Arizona Driver License Number Street Address City State Zip Mailing Address (if different from Street Address) City State Zip Statutory Agent Must be an Arizona resident. Statutory Agent Name (first, middle, last suffix) Arizona Driver License Number Street Address City State Zip Mailing Address (if different from Street Address) City State Zip Contact Person The person named below is the contact person authorized to perform all functions in connection with the day to day operations of this entity, including communication between the business and ACNSC. Contact Person Name (first, middle, last suffix) Title

2 Applicants Applicants, partners, sole proprietor and all stockholders owning 20% or more of the entity. Applicant Name (first, middle, last suffix) Title Driver License Number State Yes No Within the past 5 years, has any person on this application had a similar license revoked in this or any other state? If Yes, complete the following. Applicant Name (first, middle, last, suffix) Year License Was Revoked Business Name State Country Site Information This portion must be completed in full. Please indicate N/A if not applicable. Established Place of Business to be Licensed Yes No N/A Will the building be devoted principally to the school business? If No, provide reason: The place of business is a: Building Suite Trailer Yes No N/A If suite, does it have its own private entrance from the outside? Yes No N/A If trailer, is it permanently affixed? Must attach photos as follows: Sign indicating hours of operation Entrance of both office and classroom Front and back view of classroom Office area and secured records storage Record Keeping Yes No Will the records be maintained at the Established Business Address shown on the front? If No, where will records be maintained? Yes No N/A If a residence, is there space designated for storage of records? Certification By submitting this application, I certify that all information provided is true and correct, and that all fingerprint clearance cards submitted are true and exact copies of the original. I understand that any misrepresentation or misstatement in the application may cause the application to be denied. If individual, must be signed by owner. If partnership, must be signed by all partners. If corporation, must be signed by one corporate officer. Applicant Name (first, middle, last suffix) Applicant Signature Date

3 Current Company Name (official business name on record with MVD) School License Number Current Doing Business As (DBA) Company Name Change Only Company structure, business type, has not changed. If business type has changed, submit a new Traffic Survival School Training Application form. Requested New Company Name Requested New Doing Business As (DBA) Add Branch License (expires December 31 st ) each branch license requires a separate $50.00 fee (see next page) Add/Change Routes (provides new narratives, as applicable) Change: Old New Business Hours Contact Person Qualifying Person Established Place of Business Mailing Address Statutory Agent Business Manager Change Fingerprint clearance card is required if new manager owns 20% or more stock in the entity. Business Manager Name (first, middle, last suffix) Arizona Driver License Number Stock % Residence Address City State Zip Mailing Address (if different from Residence Address) City State Zip Other Change or Update Requested (please be specific)

4 Branch License Requests Additional offices/classrooms must be located in the same county as Established Business Address (primary office/classroom) shown on the authorization application. Each additional branch requires site information below and payment of a separate branch fee prior to conducting any business at the branch. Additional offices/classrooms located in a different county, will be considered a new Established Business Address and require a new Traffic Survival School Training Application form and fee. If more than one branch is requested, use additional copies of this form. Branch Type (branch fee required) County School Branch Number Office Classroom Both Branch Address City State Zip Site Information This portion must be completed in full. Please indicate N/A if not applicable. Established Place of Business to be Licensed Yes No N/A Will the building be devoted principally to the school business? If No, provide reason: The place of business is a: Building Suite Trailer Yes No N/A If suite, does it have its own private entrance from the outside? Yes No N/A If trailer, is it permanently affixed? Must attach photos as follows: Sign indicating hours of operation Entrance of both office and classroom Front and back view of classroom Office area and secured records storage Record Keeping Yes No Will the records be maintained at the Established Business Address? If No, where will records be maintained?: Yes No N/A If a residence, is there space designated for storage of records? Certification I certify that all information provided is true and correct, and that all fingerprint clearance cards submitted are true and exact copies of the original. I understand that any misrepresentation or misstatement may cause the request to be denied. If individual, must be signed by owner. If partnership, must be signed by all partners. If corporation, must be signed by one corporate officer. Owner, Partner or Office Signature Title Date 2 nd Partner Signature Date 3 rd Partner Signature Date

5 If you are applying for a license (including an agency permit, certificate, approval, registration, charter or similar form of authorization) issued by the Motor Vehicle Division for the purposes of operating a business in Arizona, you must present one of the following documents indicating that your presence in the United States is authorized under federal law. If the document presented does not contain your photo, then you must also present a government-issued document that contains your photo. All must be in English. Additional documents needed for a name change (e.g., marriage certificate, divorce decree). You must first change your name with the Social Security Administration. Arizona Driver License issued after 1996 or an Arizona ID Card I authorize ACNSC to verify my Arizona driver/id record to identify proof of authorized presence already on file. Driver License issued by another state, territory or possession of the US, except per Arizona law for the following states that do not verify lawful presence in the US: Hawaii, Illinois, Maryland, New Mexico, Utah and Washington (Washington verifies only for credentials labeled as Enhanced ) Enhanced Driver License or ID Card issued by another state, territory or possession of the US Birth Certificate or Delayed Birth Certificate issued in any state, territory or possession of the US US Certificate of Birth Abroad US Passport or Passport Card Foreign Passport with US Visa or Visa waiver I-94 I-94 Form presented without passport. If without photo, must also provide other acceptable form of state ID. US Citizenship and Immigration Services (formerly INS), Employment Authorization Document (I-688A, I-688B, I-766) US Certificate of Naturalization US Certificate of Citizenship Tribal Certificate of Indian Blood Tribal or Bureau of Indian Affairs Affidavit of Birth Any other license that is issued by the federal government, any other state government, an agency of this state or a political subdivision of this state that requires proof of citizenship or lawful alien status before issuing the license Company Name Doing Business As Applicant Name (first, middle, last, suffix) AZ Driver License/ID Number (if applicable) Residence Address City State Zip Applicant Signature ACNSC Internal Use Only Document Type Issue Date Expiration Date Source Document Information Business Unit Traffic Survival School Reviewer Signature Reviewer Userid Date Reviewed