VIRGINIA DRIVER IMPROVEMENT PROGRAM DIC 552A (08/01/2020)

ONLINE DRIVER IMPROVEMENT CLINIC

ELECTRONIC CERTIFICATE OF
COMPLETION
Purpose: Use this form to create a DMV approved certificate for customers that have successfully completed an eight-hour
driver improvement clinic course and final test online.
Instructions: Complete all sections with online course completion information. Check the "Certification Statement" to generate a
certificate for the student.

STUDENT INFORMATION
STUDENT FULL LEGAL NAME (last, first, middle, suffix)
LAST NAME
THOMPSON
FIRST NAME
THOMAS
MIDDLE NAME
SAMUEL
SUFFIX (if applicable) BIRTH DATE (mm/dd/yyyy) CUSTOMER NUMBER DATE OF CLINIC COMPLETION (mm/dd/yyyy)
II 09/20/1953 T62925808 03/21/2022

ONLINE DRIVER
ONLINE DRIVER IMPROVEMENT
IMPROVEMENT CLINIC
CLINIC PROVIDER
PROVIDER INFORMATION
ONLINE CLINIC PROVIDER NAME (as it appears on the license)
INFORMATION DMV-ISSUED CLINIC CODE
A&AAA Be Better Drivers 5146
EMAIL ADDRESS TELEPHONE NUMBER
greg@bebetterdrivers.com 804-748-2851

REASONS FOR TAKING ONLINE DRIVER IMPROVEMENT CLINIC (check appropriate box)
Note: Drivers can only receive up to five safe driving points
Check ONE Reason Code Safe driving points information Description of Reason

Court-No Points Driver did not present documentation from court to

No safe driving points are awarded.
Awarded receive safe driving points.

Court-Points Driver presented documentation from court to receive

Safe driving points are awarded.
Awarded safe driving points.

DMV (Points
Drivers age 18 and over will receive safe driving points.
Awarded, if Safe driving points are awarded, if eligible.
Drivers under age 18 will not receive safe driving
eligible)
points.
INS (No Points Driver completing clinic to receive insurance
No safe driving points are awarded.
Awarded) premium discount.

VOL (Points
Awarded, if Safe driving points are awarded, if eligible. Drivers completing clinic voluntarily.
eligible)

ONLINE DRIVER IMPROVEMENT CERTIFICATION STATEMENT

By issuing this electronic certificate of completion, I hereby certify and affirm that the above-named person's identity was verified
and that person successfully completed the eight-hour online driver improvement course. I make this certification and affirmation
that the information presented on this form is true and correct and under penalty of perjury and I understand that falsifying any
information on this form for any individual is a criminal violation and will result in immediate action by the department including
the assessment of a civil penalty.