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DE99

School Information
Instructor’s Name:
First Mike
Last: Vermillion
Instructor’s Phone: 316-706-9722
Instructor’s email: motorcycleridereducation@gmail.com
Motorcycle Rider Education 4600 W Kellogg Wichita, Ks 67209

Student Information
Legal Name as it appears on Driver’s License:
First:
Middle:
Last:
Suffix:
Phone Number
Address: City State:
Zip:

Sex:

Male

Female

Date of Birth:
Eye Color:
Corrective Lenses:

Yes

Height: Ft. In. Weight in
lbs.:

Medical, Vision and License Questions
Are you a resident of Kansas?

Yes

In the last 6 months, have you attempted to take and pass any testing at a Kansas Driver’s
License Exam Station?

Yes

If yes, when?
Do you have any physical limitations that may require car modifications?

Yes

Do you currently have any physical, medical, vision or mental condition(s) that could make it
difficult to operate a motor vehicle safely?

Yes

If yes, name of condition(s):
Have you suffered a seizure in the last six months?

Yes

If yes, describe type and occurrence date:
Are you currently enrolled in drug rehabilitation or a habitual user of drugs or alcohol?

Yes

If yes, describe:
Do you have a current Kansas driver’s license?

Yes

DL
Number
Is your license now or has it ever been suspended/restricted/revoked in Kansas or any other
state?

Yes

If yes give date and reason.
Reason:

Restricted

Suspended

Revocation date:

Has your license/permit been surrendered to law enforcement due to the refusal or failure of a
chemical test for drugs or alcohol?

Yes

If yes, describe:
Is your license/permit suspended/canceled/revoked by any court pending review?

Yes

If yes, describe:
Are you lawfully present in the United States?

Yes

The driving school instructor acknowledges that he or she understands that the applicants
lawful presence documentation must be copied and retained by the driving school for a period
of two (2) years.

The driving school instructor declares that he or she has inspected the lawful documentation
submitted by the applicant and has retained a copy for State audit purposes.
The driving school instructor acknowledges that his or her failure to retain appropriate lawful
presence documentation from the applicant for State auditing purposes shall constitute prima
facie evidence that such lawful presence requirements were not required and justify the State’s
to immediate prohibit the driving school instructor from obtaining and issuing driving permits.

I declare under penalty of perjury that the above and forgoing responses are true and correct.
Executed on the date this application is submitted to the State electronically.
Check Box if you so declare. If you do not make such declaration, you will not be permitted to
proceed with this permit application.

I declare

Vision Acuity: Right Eye 20/ Left Eye 20/
Do you need Vision Correction?

Yes

If no, give last date vision was checked

Do you understand that your answers to these questions, if answered falsely, may be grounds
for prosecution?

Yes

The above information supplied for data entry has been transferred to the Driver’s Education
Portal and is true and factual to the best of my knowledge.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Signed by Mike Vermillion
Signed On: April 26, 2024

Timestamp

Audit

March 16, 2024 4:43 pm CDT

DE99 Uploaded by Mike Vermillion - design@pixelcrownstudios.com IP 172.59.122.221