Instructor's Application

Fill out the application to become a Seniors For Safe Driving instructor.

Click at the bottom of this page and your application will be submitted to us.

Please give us up to ten days and we will contact you to arrange a meeting.

City:   State:   Zip:
Date of Birth: Home phone:
Cell phone: Fax number:

Do you have a Pennsylvania Driver’s License? Yes    No If Yes, Operator Plate Number:
Are you violation free the past 3 years? Yes    No If No, Type of Violation:
Have you ever had a D.U.I.? Yes    No If Yes, When?
Are you retired from your career position? Yes    No If Yes, Date of Retirement:
Are you willing to teach up to 35 classes a year? Yes    No If No, How many?
Are you a college graduate? Yes    No If Yes, College or University:
Degree earned:
Additional Education:
Related Work Experience: (ie: Highway Safety - Teaching - Seminar Presentations - Management - Education)