MVA BTW Form (Allegany County)

MARYLAND DEPARTMENT OF TRANSPORTATION

Behind The Wheel Student Record
First Name*
Middle Name*
Last Name*
Phone #*
Street Address*
City*
County*
State*
Zip Code*
Student Email
example@example.com
Name of Driving School
Branch
School Number
Date of Birth*

MonthDayYear
Student Age*
Permit Number (Customer Identifier)*
NO SPACES or DASHES
Driving Appointments

Enter Student Driving Hours Below
Appointment 1
Appointment 2
Appointment 3
Hours
Hours
Hours
Date Appointment 1*

MonthDayYear
Date
Appointment 1 Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Lesson 1 Comments
Lesson 1 Performance*
Date Appointment 2*

MonthDayYear
Date
Appointment 2 Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Lesson 2 Comments
Lesson 2 Performance*
Date Appointment 3*

MonthDayYear
Date
Appointment 3 Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Lesson 3 Comments
Lesson 3 Performance*
Tag Number*
Instructor Initials*
Instructor ID #*
E-Signature
Date

MonthDayYear
Date
Date*

MonthDayYear
Date
Student Evaluation

Instructor must evaluate the student performance below.
Instructor Name*
Evaluation (Check all that have been completed successfully)*

Pre-EntryEnter and SecureAdjustmentsStarting TasksBasic Vehicle ControlHead ChecksStaggered StopsLane SelectionLane PositionCorneringFollowing DistanceRight of WayTurn Signal UseTraffic Sign AwarenessTraffic Signal AwarenessLeft TurnsRight TurnsLane ChangesMergeRisk AwarenessBacking3 Point Turn2 Point TurnParallel ParkPerpendicular Park
Final Score
Parent Ride Along*
Yes or No
Debrief*
Yes or No
Final Score*
Please verify that you are human*
Student Signature

Clear
Instructor Signature

Clear
Date*

MonthDayYear
Date
Date*

MonthDayYear
Date
Lesson Grade
Should be Empty:

MARYLAND DEPARTMENT OF TRANSPORTATION

Driving Appointments

Student Evaluation