Transcription of STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND …
1 STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES parent proctoring OF ON-LINE DRIVER LICENSE TESTING BY A MINOR I do hereby affirm that I was present when the STATE of FLORIDA knowledge test for a Class E Learner s License was completed on-line by my child or ward_____, a minor, First Middle Last date of birth _____. I attest from my own observation that the named applicant responded to the items on the Class E Knowledge test without reference to other materials and without assistance from another person, including myself. Printed name of Parent or Legal Guardian: Signature of Parent or Legal Guardian: STATE OF FLORIDA , COUNTY OF Sworn to (or affirmed) and subscribed before me this _____day of_____, 20_____, by _____ who is personally known to me or produced Identification _____ as proof.
2 (Identification type and number) _____ Notary Public or DL Examiner/Agent-Signature _____ Print, Type, or Stamp Commissioned Name of Notary Public INSTRUCTIONS: 1. The parent or legal guardian of the on-line tested applicant must sign this form. 2. All signatures must be notarized or witnessed by an examiner. HSMV 71144 (Rev 03/15)
