FOR TEA USE ONLY:
SIX-HOUR DRIVING SAFETY COURSE APPLICATION
TITLE 5, TEXAS EDUCATION CODE, CHAPTER 1001
TEXAS DRIVER AND TRAFFIC SAFETY EDUCATION
APPLICATION FEE: $9,000
APPLICATION FEE IS NON-REFUNDABLE
TEXAS EDUCATION AGENCY
1701 NORTH CONGRESS AVENUE
AUSTIN, TEXAS 78701-1494
AUTHORITY FOR DATA COLLECTION: Title 5, Texas Education Code, Chapter 1001.
PLANNED USE OF DATA: To provide information necessary to determine if the driving safety course
meets the criteria for approval under Chapter 1001, Texas Driver and Traffic Safety Education.
INSTRUCTIONS: The Agency will not act upon any application until all the required documentation, fees,
and other materials have been received. If additional clarification is required, contact Driver Training at
MAIL CHECKS AND ALL ATTACHMENTS WITH THIS APPLICATION TO:
REGULAR MAIL: FOR OVER-NIGHT EXPRESS MAIL:
TEXAS EDUCATION AGENCY – DTS COMPTROLLER OF PUBLIC ACCOUNTS
P.O. BOX 13717 TREASURY OPERATIONS
AUSTIN, TEXAS 78711-3717 BANKING & ELECTRONIC PROCESSING LOCKBOX
200 EAST TENTH STREET
AUSTIN, TEXAS 78701-2436
Texas Education Agency Page 1 of 4 DS-263TDM (Rev. 12/15/05)
1. LEGAL NAME OF DRIVING SAFETY COURSE:
The driving safety course name will be approved exactly as it appears below.
2. LEGAL NAME OF COURSE OWNER:
3. TYPE OF OWNERSHIP: (check one)
Driving safety courses owned by a partnership must submit a copy of the partnership agreement. Driving safety
courses owned by a corporation must submit a copy of each stock certificate, issued and outstanding, and a copy of
the articles of incorporation.
Individual Partnership Corporation Other legal entity (Please provide an explanation)
4. COURSE OWNER INFORMATION:
List the individual; all partners; or all officers, directors, and/or trustees of a corporation. Corporations must list each
shareholder owning stock aggregating at least 10% of the total issued and outstanding shares. SUBSIDIARY
CORPORATIONS should list the parent corporation as stockholder. (Use an additional sheet, if necessary, and
identify as Attachment 1.)
Name Title Address Telephone # % Owned
5. PHYSICAL ADDRESS OF COURSE OWNER:
City State ZIP Code
6. MAILING ADDRESS OF THE COURSE OWNER:
City State ZIP Code
7. TELEPHONE NUMBER(S) AND E-MAIL OF COURSE OWNER:
( ) ( )
Voice Facsimile E-Mail address
Texas Education Agency Page 2 of 4 DS-263TDM (Rev. 12/15/05)
8. BUSINESS SIZE: The information below is optional and is collected to determine how to process documentation from the school.
(Check the appropriate box.)
YES NO The corporation, partnership, sole proprietorship, or other legal entity was formed for the purpose of making a profit.
YES NO The corporation, partnership, sole proprietorship, or other legal entity is independently owned and operated.
YES NO The corporation, partnership, sole proprietorship, or other legal entity has fewer than 100 employees.
YES NO The corporation, partnership, sole proprietorship, or other legal entity has less than $1 million in annual gross receipts.
9. REQUIRED DOCUMENTS:
Please refer to the CHECK SHEET FOR COMPLETION OF THE APPLICATION PACKET (Form DS-266) for a
complete list and description of documents that must be submitted with this application for driving safety course
INVENTORY CHECKLIST OF VIDEOS, TAPES, AND VISUAL MEDIA (Form DS-260)
APPLICATION AND OWNER’S AFFIDAVIT (Form DS-263TDM)
DRIVING SAFETY COURSE REQUIREMENTS (Form DS-264)
CROSS REFERENCE FORM FOR A SIX-HOUR DRIVING SAFETY COURSE (Form DS-268)
DRIVING SAFETY FEE SHEET (DS-299)
10. TYPE OF DELIVERY:
11. REQUIREMENTS FOR AUTHORSHIP:
The course materials shall be written by a TEA-licensed driving safety instructor or other individuals or organizations
with recognized experience in writing instructional materials with input from a TEA-licensed driving safety instructor.
List all educational and experience qualifications that should be considered regarding the approval of this
12. COURSE AUTHOR’S TELEPHONE NUMBER AND FACSIMILE NUMBER:
( ) ( )
13. OWNER’S AFFIDAVIT:
PLEASE NOTE: A separate affidavit must be submitted for each partner or corporate shareholder. Photocopy the
following affidavit and have a copy completed and notarized by each partner or shareholder. Submit the additional
affidavit(s) as part of the original application.
Texas Education Agency Page 3 of 4 DS-263TDM (Rev. 12/15/05)
IF THE COURSE CURRICULUM IS OWNED AND/OR CREATED, PRODUCED, OR COPYRIGHTED BY AN
INDIVIDUAL, THE AFFIDAVIT MUST BE SIGNED BY THE INDIVIDUAL. IF THE COURSE CURRICULUM IS
OWNED AND/OR CREATED, PRODUCED, OR COPYRIGHTED BY A CORPORATION, THE AFFIDAVIT
MUST BE SIGNED BY THE SHAREHOLDER(S) OWNING STOCK AGGREGATING AT LEAST 10% OF THE
TOTAL ISSUED AND OUTSTANDING SHARES.
STATE OF , COUNTY OF
I, (Typed or Printed Name) ,
being duly sworn, depose and say that the information in this application, accompanying
documentation, and materials is true and correct; and I understand that purposely submitting false
or misleading information on this application may subject me to a fine, a prison sentence, or both.
I do hereby state that I have read Driver Training Programs Commissioner’s Rules and Title 5, Texas Education Code,
Chapter 1001 and understand them.
I do hereby agree, consent, and direct that any person or entity maintaining information in any form relating to my
criminal history shall release all such information upon the request of the Texas Education Agency.
I do hereby agree and permit the Texas Education Agency to obtain from any person or entity information relating to my
personal background, reputation, and character, and do hereby expressly direct that any such person or entity release
such information upon the request of the Texas Education Agency.
I do hereby release, discharge, and exonerate the Texas Education Agency, its agents or representatives, and any
person or entity so furnishing information from any and all liability of every kind arising therefrom.
I do hereby agree to inform the Texas Education Agency of any move, addition, or changes to the data processing
system, operating system, or organizational rules maintained by the course owner that could impact the confidentiality
of any part of the system of records, applications, operating systems, or hardware used by the course owner.
I do hereby agree that after the course approval, the Texas Education Agency will be informed of proposed changes to
the course and student validation records, and no changes will be implemented without written approval signed by the
I do hereby agree that if this course approval is terminated, all student data will be delivered to the Texas Education
Agency within seven (7) calendar days.
The foregoing consent and release is valid and binding so long as I hold or seek any certificate, license, or permit under
the authority of Title 5, Texas Education Code, Chapter 1001.
Signature of Owner, Partner, or Authorized Corporate Shareholder
Legal Name of Course as shown on Page 2 of Application for Approval
SUBSCRIBED AND SWORN BEFORE ME THIS
DAY OF , 20
Texas Education Agency Page 4 of 4 DS-263TDM (Rev. 12/15/05)