SF1256 Certification of 50 Hours Behind the Wheel …

1 SF-1256 (02/13) PLEASE PRINT ALL INFORMATION CLEARLY IN BLACK INK Learner Permit Class PD Intermediate Restricted Intermediate Unrestricted Regular Class D NEEDS: At least 15 years old At least 16 years old At least 17 years old At least 18 years old Vision Exam Must have held a valid PD Held a valid Restricted OPTIONAL: Can apply Knowledge Test for a minimum of 6 months Intermediate for 1 Year For a duplicate license, SF 1010 Form Certification of 50 Hours CANNOT have: without the word (Proof of Compulsory Behind the Wheel experience, *6 or more points on driving "intermediate" School Attendance & including 10 Hours at night *have an at fault traffic crash on its face Satisfactory Progress) CANNOT have.

2 *have a 2nd seatbelt violation Parent or legal guardian *6 or more points on driving record (this will add a 90 day waiting must sign Teenage Affidavit during the 180 days immediately period to the end of the one year of Financial Responsibility preceding application Intermediate Restricted duration) Certified Birth Certificate Vision Screening Proof of Citizenship or Road Skills Test Lawful Permanent Resident Status FEES: $ , any age under Age 16 =$ Age 17 = $ $ or $ regular 18 years old Age 17 =$ Age 18 = Eligible for regular driver duplicate fee depending Age 18 Eligible for regular license at regular license fees upon if 1st or subsequent driver license at regular ($ duplicate fee if had duplicate license license fees.)

3 Intermediate license) ISSUED FOR: 12 MONTHS UNTIL AGE 21 SAME EXPIRATION DATE AT AGE 21 SAME EXPIRATION DATE AT AGE 21 RESTRICTIONS: Must have licensed driver Only one passenger Safety belts mandatory for all No restrictions age 21 or older in front seat Cannot drive between 11:00 PM passengers age 4 through and license looks Cannot drive between and 6:00 AM 17 (or child restraint device Like Under 21 10:00 PM 6:00 AM Safety Belts mandatory for all if under age 4) license Safety Belts mandatory for passengers age 4 through No additional restrictions but all passengers age 4 through 17 (or child restraint device license still states "intermediate" 17 (or child restraint device if under age 4) on the front of license if under age 4) TENNESSEE DEPARTMENT OF SAFETY AND HOMELAND SECURITY DRIVER SERVICES DIVISION NAME OF PERMIT HOLDER: TENN PERMIT NUMBER: SOCIAL SECURITY NUMBER.

4 STREET ADDRESS CITY STATE ZIP CODE NAME OF PARENT, GUARDIAN OR LICENSED INSTRUCTOR: DRIVER LICENSE NUMBER: SOCIAL SECURITY NUMBER: ADDRESS CITY STATE ZIP CODE PD At least 6 Months Level 1 At least 12 MonthsLevel 2 Until Age 18 Level 3 Certification OF 50 Hours Behind THE Wheel DRIVING EXPERIENCE I affirm that I am the above named parent/guardian or licensed instructor, and I certify that the above named permit holder (under the age of 18) has completed fifty (50) Hours of Behind the Wheel driving including a minimum of ten (10)

5 Hours of driving at night. X_____ Relationship to Permit Holder: _____ Signature of parent, guardian or licensed instructor (Parent, Step-Parent, legal guardian)