Texas Department of Licensing and Regulation

1 Texas Department of Licensing and RegulationSTUDENT AFFIDAVITOnce complete, please email a scan or photo of the affidavit and ID for , , ,Legal Name (printed or typed)Mailing Address , , ,CityStateZIP Code ,Driver's License Number (if applicable) ,State Issuing Driver's Licensemake the following Statement:I have read and accepted the 's Student Enrollment Contract and Terms of Agreement for their Aware Driver Course.

2 I personally attended and completed or am planning on attending and completing the afore-mentioned six-hour driving safety course in accordance with the policies and procedures of the course. I did not receive any assistance to complete this course other than assistance from the school's technical support staff or instructors. I have not attempted to misrepresent my identification in any way while taking this driving safety course. A copy of my driver s license or equivalent type of photo identification is shown on this page. SignatureSTATE OF COUNTY OF ORIGINAL EMAILED/FAXED ON DatePersonally appeared before me, the above-named , known to me,who provided the document copied above, and who being duly sworn.

3 Deposes and says that she/heexecuted this affidavit and that the statements and representations contained therein are true and correct tothe best of her/his knowledge and AND SWORN before me this day of , 20 notary Public (signature)SEALCOMMISSION EXPIRES: COPY PICTURE ID HEREINSTRUCTIONS FOR COMPLETION OF THE AFFIDAVITC omplete the following fields on the affidavit Legal Name (printed or typed) Mailing Address City State Zip code Drivers License Number (if applicable) State Issuing Drivers LicenseMake a photocopy of your drivers license or picture ID and affix it to the form in the square that states COPY PICTURE ID HERE.

4 Present the form to a notary and present your ID to them. (Most banks have a notaryon site during business hours or you can look for a notary in your local yellow pages) In the presence of the notary , sign the form and add the State and County in thespaces provided. The notary will review your ID and notarize the form by signing the form themselvesand placing an official notary stamp on the form. Please make sure the stamp is boldand clear. Make a photocopy of the completed form for your records Mail the ORIGINAL to us Box 9689 Fleming Island, FL 32006 Affidavit Express delivery optionsFor expedited processing, you can email (scan or photo) your completed affidavit You are still required to mail the originalform to the above address. Remember, you will not be able to finish the course until we receive your affidavit.

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