DRIVING SAFETY CLASSROOM LOCATIONS AND INSTRUCTORS by 67U5j0

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									   DRUG AND ALCOHOL DRIVING AWARENESS MULTIPLE CLASSROOM LOCATIONS AND INSTRUCTORS
INSTRUCTIONS:              This form is used to notify the Texas Education Agency of all drug and alcohol driving awareness multiple classroom locations. The form also serves as a statement that the
parent drug and alcohol driving awareness school has approved all listed multiple classroom locations. Any additions or revisions to the school’s list of drug and alcohol driving awareness classroom
locations will be submitted to the Texas Education Agency for approval prior to advertising or offering a drug and alcohol driving awareness course at the location. Authority for data collection is Article
4413(29c),VTCS and Subchapter CC, Chapter 176, Title 19, Texas Administrative Code.

________________________________________________________________                                                                  _______________________                          ___________________
 SCHOOL NAME                                                                                                                      SCHOOL LICENSE NUMBER                                        DATE

__________________________________________________________________________________________________________________________________
 SCHOOL PHYSICAL ADDRESS                                                                        CITY                                     STATE                                     ZIP CODE

_________________________________________________________________________________________________________________________________
 PROGRAM(S) TAUGHT


I affirm that the information provided is true and correct, all instructors employed or affiliated with the above-named
drug and alcohol driving awareness school are properly licensed and endorsed, and only the programs designated are being            __________________________________________ ______-______-____
taught by the instructors.                                                                                                          Signature of School Owner                                   mo. / day / yr.

I affirm that the classroom(s) at each location on this list meet all requirements established by Subchapter CC, Chapter 176,       _________________________________________________
Title 19, Texas Administrative Code, and that no alcohol is present at the location. All additions or revisions to the school’s     Typed or Printed Name of School Owner
multiple classroom listings will be submitted to the Texas Education Agency for approval prior to advertising or offering a
drug and alcohol driving awareness program at those locations.

NAME OF FACILITY                       TYPE OF BUSINESS              ADDRESS OF CLASSROOM                   CITY                    ZIP      (A/CODE)           INSTRUCTOR NAME                   TEA
(Provide name of: buildings , mall,    (Describe nature of                                                                                                      (Primary instructor for this
                                       “primary” business
                                                                     FACILITY                                                       CODE     TELEPHONE                                            LICENSE #
shopping ctr., business plaza, etc.)
                                       conducted at the facility.)                                                                           NUMBER             location)

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THIS FORM MAY BE DUPLICATED                                                                                                                       PAGE ______ of ______                                 DA-243
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MULTIPLE CLASSROOM LOCATIONS (Continued): ______________________________________________________________________________________
                                                                                   School Name and License Number

NAME OF FACILITY                       TYPE OF BUSINESS              ADDRESS OF CLASSROOM            CITY           ZIP    (A/CODE)     INSTRUCTOR NAME                TEA
(Provide name of: buildings , mall,    (Describe nature of                                                                              (Primary instructor for this
                                       “primary” business
                                                                     FACILITY                                       CODE   TELEPHONE                                   LICENSE #
shopping ctr., business plaza, etc.)
                                       conducted at the facility.)                                                         NUMBER       location)

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THIS FORM MAY BE DUPLICATED                                                                                                    PAGE ______ of ______                         DA-243
                                                                                                                                                                       Original 12/99

								
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