I do hereby consent that___________________________________________________________, a minor,
                                            First               Middle               Last

date of birth _________________________ be granted a Florida driver license and assume the obligations imposed by Section 322.09, Florida Statutes, unless and until I notify the Department to withdraw this consent.
________________________________________ __________________________________
Signature of Parent, Legal Guardian Print Name

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 or legal guardian must sign this form.
2. All signatures must be notarized or witnessed by an examiner.
3. Present this form, a social security card (if you have been issued one), and proof of identity satisfactory to the Department of Highway Safety and Motor Vehicles, if under 18 years of age. This form is not required if married.

A PARENT, LEGAL GUARDIAN, OR RESPONSIBLE ADULT (OVER 21 YEARS OF AGE)MUST ACCOMPANY A DRIVER HOLDING A LEARNER'S LICENSE
Drivers under 18 years of age must meet the following criteria before they are eligible to apply for a Class E License:
• Hold a Learner's License for a minimum of 12 months.
• No traffic convictions 12 months prior to making a Class E application, or
• One non-criminal traffic conviction where an election to complete a basic driver improvement course wherein the points were not assessed by the clerk of court (adjudication withheld).
• Parent, legal guardian or other responsible adult over 21 years of age must certify in person or by notary that the applicant has completed 50 hours of behind the wheel experience, of which 10 hours was night-time driving.
HSMV 71022A (0706)