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Better Business Bureau New Mexico

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					                                                                                revised 11/15/2010

               New Mexico State Highway and Transportation Department
                                Traffic Safety Bureau
                                 604 West San Mateo
                                    PO Box 1149
                          Santa Fe, New Mexico 87504-1149
                        Phone: (505) 827-0427; (800) 541-7952
                                 Fax: (505) 827-0431

                       Driving While Impaired (DWI) School
                              Facilitator Application
                               Section 1: Facilitator Information
Please print or type




Facilitator Name


Facilitator Business Address


Facilitator Mailing Address (if different)


Telephone Number                               Fax Number


Toll Free Number (if applicable)               E-Mail Address (if applicable)


Web Address (if applicable)



DWI School Address/City/State/Zip where employed



Contact Person at the DWI School Facility




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                                    Section 2 References
           Employment and character references. References cannot be family members.


1
    Name




    Address




    Relationship                                       Telephone Number


2
    Name




    Address




    Relationship                                       Telephone Number


3
    Name




    Address




    Relationship                                       Telephone Number




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                                              Section 3
                                              Submittals
The following must be submitted by all applicants:

Copy of the applicant's limited history driving record from the Motor Vehicle Division, Driver Services
Bureau dated no earlier than 60 days before the date the application is filed with the Bureau.

State police background check on the applicant dated no earlier than 60 days before the date the
application is filed with the Bureau, or verification that the applicant submitted a request for a State
Police background check to the Department of Public Safety at least sixty (60) days before the date the
application is filed with the Bureau. (Use enclosed DPS form or obtain at www.dps.nm.org. Form is
located under Frequently Asked Questions.

Copy of the applicant's health certificate signed by a physician and dated no earlier than sixty (60) days
before the date the application is filed with the Bureau stating that the applicant is free all communicable
diseases.

Applicant's resume or curriculum vitae.

Applicant's transcripts from any post secondary educational or training institutions the applicant has
attended.


                                Section 4
     (Current Facilitators) Standards for Issuance of DWI Facilitator
                                Certificate

Do not send fees at this time. The Bureau will request items
upon review and approval of this application.

The Bureau will issue a certificate upon payment of the $50.00 facilitator certification fee.


Pay the $50.00 annual certification fee.


Meets the standards specified in subsection E of 7.32.20.16 NMAC


Received an overall rating of satisfactory or better in the periodic evaluations conducted by the Bureau
or its designee in the preceding year; and


Has completed twelve (12) credit hours of continuing education in the year preceding the application for
renewal.
Continuing Education credit hours: Course_______________________________ Date __________
                                      Course_______________________________ Date __________
                                      Course_______________________________ Date __________
                                      Course_______________________________ Date __________
                                      Course_______________________________ Date __________

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                              Section 5
    (New Applicants Only) Standards for Issuance of DWI Facilitator
                             Certificate
In reviewing applications for DWI Facilitators, the Bureau shall consider whether:

The information provided is accurate and valid; the character and employment references provided by
the applicant report that the applicant is fit to be a DWI facilitator; the applicant is at least twenty-one (21)
years of age; the applicant has a high school diploma or equivalent; the applicant holds a valid driver's
license; the applicant has not been convicted of a crime involving moral turpitude; and the applicant has
a clean driving record.

Each applicant for a certificate as a DWI facilitator must satisfactorily complete the New Mexico DWI
facilitator course, as verified by the Bureau;

TSB- Facilitator Training Course Date:

Attend a DWI trial in a court in the community, as verified by the clerk of the court;

Signature of Clerk of court:                                                    Date:

Observe a minimum of one complete twelve-hour DWI program, as verified by the certified DWI
facilitator conducting the program; and

Signature of Certified DWI facilitator :                                         Date:

Co-facilitate at least six (6) hours of a DWI program under the direct supervision of a certified DWI
school facilitator, as verified by that facilitator.

Signature of DWI school facilitator:                                            Date:

The Bureau will issue a certificate upon payment of the $50.00 facilitator certification fee.

Pay the $50.00 annual certification fee. (Do not send fees at this time. Bureau will request fees.)

Meets the standards specified in subsection E of 7.32.20.16 NMAC


Do not send fees at this time. The Bureau will request items
upon review and approval of this application.




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                                            Section 6
                                           Certifications
It is understood that no person shall conduct DWI facilitator services in New Mexico until this Application
and Agreement has been signed and approved by the Traffic Safety Bureau. Upon approval of the
application, the applicant will receive a certificate.


The Provisions in this application and agreement.

Rule 18 NMAC 7.32.20 titled "Driving While Impaired (DWI) Schools."



      Failure to abide by any of the above requirements shall be grounds for
      Revocation and/or Termination of the issued license and certification.

      Signature of applicant:
       Printed name/ date:

                    Traffic Safety Bureau use. To be completed by Program Manager.
     Approved:
    Not Approved:
        Date:




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