Please use this chart to record mandatory practice driving session data. Note that a parent or guardian, who is over age 21 and has been a licensed driver for at least one year, must fill out the signature blank at the end.

Date	Location of practice (highway, residential area, etc.)	Time of day	Weather conditions	Time spent	Initials of supervising adult

print applicant’s name and permit number in ink

Date	Location of practice (highway, residential area, etc.)	Time of day	Weather conditions	Time spent	Initials of supervising adult

Enter total practice hours here. This form may be

photocopied if space for additional entries is required.

I hereby certify that ,

who bears instruction permit # , has completed a minimum of 30 hours of behind-the-wheel driving practice and is sufficiently prepared and able to safely operate a motor vehicle. I understand that all of the said 30 hours must have been conducted under the supervision of an adult 21 years of age or older, who has been licensed to drive for at least one year. Under penalty of perjury, I swear or affirm that all information submitted herein by me regarding this certification is true, correct and complete.

signature and driver’s license number of parent or guardian

date

NCF 5853 7/28/2000

Please use this chart to record mandatory practice driving session data. Note that a parent or guardian, who is over age 21 and has been a licensed driver for at least one year, must fill out the signature blank at the end.

Date

Date

Enter total practice hours here. This form may be