Dl-90a - Driver Education Affidavit printable pdf download

Take this form to the DPS to apply for the Instruction Permit.

DRIVER EDUCATION AFFIDAVIT

I, ______________________________, valid driver license number_______________________________,

(Instructor’s Name)

hereby certify that I am the instructor of, _________________________________,

(Student’s Legal Name)

a person who is legally required to successfully complete a driver training course to obtain a

Class C driver’s license. The student’s date of birth is _________________________________.

(MM-DD-YYYY)

I further certify that I have not been convicted of Criminally Negligent Homicide or Driving

While Intoxicated and that I am not disabled because of mental illness.

I further certify that I have instructed or am instructing my student in the following Department of

Public Safety approved course of instruction: (mark only one area of instruction).

•

32 hours of classroom block instruction.

Approved textbook used _________________________________

•

32 hours clasroom instruction concurrent with laboratory.

•

Other DPS-approved classroom instruction (Course 102 or 103)

C o u r s e 1 0 2

Title of DPS Approved Curriculum used ____________________________

Driver Education Certificate, form DE-964, # ________________________

(completed at driver license office)

I acknowledge that falsely certifying the Texas Driver Education Certificate, form DE-964, is

punishable as a third degree Felony, under Article 4413 (29c), V.T.C.S., which includes imprisonment

for a period not to exceed five years.

_____________________________________

______________________

(Signature)

(Date)

Sworn to and subscribed before me this _____ day of ________________, 20_____.

______________________________________

Notary Public in and for the State of Texas / Authorized Officer

PLEASE NOTE: One affidavit is required for each instructor who actually teaches a student in each

phase of the course. If there is more than one instructor, this form may be photocopied for use by the

second instructor. If both instructors are not able to accompany the student when applying for an

Instruction Permit, the affidavit for the absent instructor will need to be notarized prior to appearing in the

Driver License Office. The document(s) must be presented when the student applies for an Instruction

Permit. Definition of a qualified instructor can be found on page VIII of the instruction packet.

DL-90A (Rev. 9/99)

Dl-90a - Driver Education Affidavit