I do hereby consent 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 over 21 years of age must sign this form.
2. All signatures must be notarized or witnessed by an examiner.

HSMV 71022B (0706)