STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
CERTIFICATION OF DRIVING EXPERIENCE OF A MINOR
I do hereby certify that ___________________________________________________________ , a minor,
First Middle Last
date of birth _________________________, has driven a minimum of 50 hours during the past 12 months, of
which 10 hours of driving were at night per Section 322.05(3), Florida Statutes.
____________________________________ __________________________________
Signature of Parent, Legal Guardian or Print Name
Responsible Adult
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 of identification.
(Identification type and number)
_____________________________________________________
Notary Public or DL Examiner-Signature
_____________________________________________________
Print, Type, or Stamp Commissioned Name of Notary Public
INSTRUCTIONS:
1. One parent, legal guardian, or other responsible adult 21 years old or older must sign this form.
2. All signatures must be notarized or witnessed by an examiner.
HSMV 71143 (Rev 01/11)
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