ONLINE PERMIT TEST ATTESTATION FOR
APPLICANTS 18 YEARS OF AGE AND OLDER
ONLINE LEARNER PERMIT TESTING CERTIFICATION INSTRUCTIONS
IMPORTANT: DO NOT SIGN THIS FORM UNTIL YOU ARE WITH A MOTOR VEHICLES REPRESENTATIVE
Full Name Date of Birth
City State Zip Code
I , do hereby affirm that I completed the New York State Department
of Motor Vehicles knowledge test for a Class D or Class M Learner Permit without the assistance of any person(s) and
without reference to materials of any kind. I understand making a false statement, or submitting any false documentation
in support of an application, may be punishable as a criminal offense.
By signing this document, I hereby represent that all above information is true and accurate.
Applicant Signature Date
Print Applicant Name