Driver Education Provider TEEN BTW INSTRUCTION RECORD

KEY = BTW = Behind-the-Wheel RAN = Range OBS = Observation

Michigan Department of State Rev. 2/2019

Name of Student Address Phone #

Provider Name Program # Certificate #

DATE START ENDHOURS*

COMMENTS INSTRUCTOR NAME STUDENT INITIALSBTW RAN

1.

2.

3.

4.

5.

6.

7.

8.

OBSERVATION (OBS)

DATE START END INSTRUCTOR NAME STUDENT INITIALS DATE START END INSTRUCTOR NAME STUDENT

INITIALS

1. 4.

2. 5.

3. 6.

TOTAL HOURS I agree I have received at least [INSERT HOURS hours of BTW instruction instructor.BTW OBS DATE INSTRUCTOR SIGNATURE DATE STUDENT SIGNATURE

Rev. 2/2019