Driver Education Certification Request Form
Registry of Motor Vehicles ● Driver Education Certificate Department
P.O. Box 55889 ● Boston, MA 02205-5889
p.1 of 3 (Continued on Back) PDS106_0218
Under the pains and penalties of perjury, I hereby confirm that the below named student(s) has satisfactorily completed all requirements of the Driver Education
Program, including the classroom component, on-road component (consisting of both behind-the-wheel and observation requirements), and if applicable, a parent,
guardian, or designee has attended the parent/guardian class at the below named driving school. Such instruction was in accordance with all applicable statutes,
regulations and guidelines set forth by the Registry of Motor Vehicles including, but not limited to, all specific curriculum requirements.
Authorized Administrator Name
Signature: _______________________________________________________________________________ Date: ________________________________
(Proprietor, Director, or Officer)
Student Name (please type or print) Permit/License # Student Email Address DOB (MM/DD/YY) Course Start Date
