School District Contact Person: Date:
School District: Phone:
Address:
Social Security Number and Name (first and last).
Example 111-22-3333, John Doe.
Additions Deletions
SSN Name SSN Name
Please list all qualified drivers who must be tested under the federal regulations. Make copies of this form if you need additional space. Changes must be made in writing. Telephone changes cannot be accepted.
Changes for a month must be received the last business day of the prior month to be effective for the month. Random list updates cannot be data entered for a new month if this form is received on or after the first of the new month.
Please fax or mail to: (Need to replace with new address)
Approved: November 1995
Reviewed: January 2017, May 2020
