<p> Form 179 E (09.13) State of Kansas</p><p>DEPARTMENT OF EDUCATION</p><p>APPLICATION FOR MOTOR VEHICLE IDENTIFICATION -- DRIVER TRAINING SCHOOL (2013)</p><p>Name of School </p><p>Address of School Street City State Zip Code</p><p>1. Is this school approved and licensed as a Driver Training School in Kansas? </p><p>2. Is this car equipped with required dual control? ______Dual mirrors ?______(Passenger visor not acceptable) Seat belts? ______Outside mirrors? ______Student Driver Sign? ______Please check all that apply.</p><p>3. Has evidence of required liability insurance (certificate of insurance with coverage amounts noted) been filed with State Commissioner of Education? </p><p>4. Does the vehicle have manual shift? ______Automatic? ______</p><p>5. Registered license plate number of vehicle ______</p><p>6. Model of car______Year ______Make of car Put additional cars on back of page.</p><p>Application is hereby made for a Driver Training School Identification certificate.</p><p>Signed </p><p>Position </p><p>Please return this completed form along with a Certificate of Insurance to Joan Peterson, Consultant, CSAS, Driver Education, LSOB, 900 SW Jackson St, Suite 653, Topeka, KS 66612.</p><p>An Equal Employment/Educational Opportunity Agency The Kansas State Department of Education does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies: KSDE General Counsel, LSOB, 900 SW Jackson St, Suite 653., Topeka, KS 66612 785-296-8107</p>