Form Dmv-Pcf-01 - Parental Consent Form To Obtain A Learner'S Permit

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Government of the District of Columbia
Department of Motor Vehicles
Parental Consent Form to Obtain a Learner’s Permit
Applicant’s Full Name
Date of Birth
Sex
Social Security #
(First, Middle, Last)
Male
Female
City
DC Address
Zip Code
Telephone #
State
Wash. DC
I hereby certify that the information provided on this document is true and accurate to the best of my knowledge and belief.
Applicant’s Signature:_______________________________________________________ Date:_____________________________
Parent
If Legal guardian, provide court decree number:
Relationship to Applicant (Check one)
*
Legal Guardian
Name Parent or Legal Guardian
Date of Birth
Sex
Telephone #
(First, Middle, Last)
Male
Female
State of
Expiration
Social
DL or Identification Card Number
E-mail address
Issuance
Date
Security #
Address
City
State
Zip code
I hereby certify that the information provide on this document is true and accurate to the best of my knowledge and belief.
Signature of Parent/Legal Guardia:_______________________________________________________Date:__________________
If parent/legal guardian is a Non-DC resident, please complete this section to certify applicant resides with
someone else.
Full Name of person applicant is residing with in DC
Date of Birth
Sex
Telephone
(First, Middle, Last)
Male
Female
DC Address
City
State
Zip
Washington
DC
DC Driver’s License # or ID Card or SSN
Expiration date
Email address
I hereby certify that the information provided on this document is true and accurate to the best of my knowledge and belief.
Certifier’s Signature: ________________________________________________________________ Date: ____________________
Please Note and Attach:
Certifier must sign and date this form and provide a valid DC Driver’s License or valid DC Identification card reflecting
the applicant’s DC address listed above AND one of the following proof of residency.
Utility Bill (Water, Gas, Electric or Oil Bill)
DC Property Tax Bill
Telephone Bill (no wireless or pager bills accepted)
Deed or Settlement Statement
Cable Bill
DC Homestead exemption certificate
Original lease or rental agreement issued in the last
Valid Homeowners Insurance Policy
12 months with the name of the certifier as a lessee or renter
reflecting names and address
DMV Examiner Signature:________________________________________________ Date:_______________________
To report waste, fraud and abuse by any DC Government agency or official, call the DC Inspector General at 1-800-521-1639.
For additional information visit our website at
or call 202-727-5000.
DMV-PCF-01 Rev. 07/26/05

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