Date
Verifier’s Initials
Driving Time
Night Driving
Comments:
Date
Verifier’s Initials
Driving Time
Night Driving
Comments:
Date
Verifier’s Initials
Driving Time
Night Driving
Comments:
Date
Verifier’s Initials
Driving Time
Night Driving
Comments:
Date
Verifier’s Initials
Driving Time
Night Driving
Comments:
Date
Verifier’s Initials
Driving Time
Night Driving
Comments:
Date
Verifier’s Initials
Driving Time
Night Driving
Comments:
Date
Verifier’s Initials
Driving Time
Night Driving
Comments:
Date
Verifier’s Initials
Driving Time
Night Driving
Comments:
Date
Verifier’s Initials
Driving Time
Night Driving
Comments:
Date
Verifier’s Initials
Driving Time
Night Driving
Comments:
Date
Verifier’s Initials
Driving Time
Night Driving
Comments:
Date
Verifier’s Initials
Driving Time
Night Driving
Comments:
Driving Time
Night Driving
Totals ...................................................................
Minimum of 50 hours
Minimum of 10 hours
The verifying signature must be from one of the signers of the Affidavit of Liability and Guardianship, form DR 2460, or from the
Driver Education Instructor. Please check all totals prior to signing. By signing below, I certify that the above total hours of
driving experience is true and accurate.
Signed ___________________________________________________________
Date ______________________
Parent/Guardian or Driver Education Instructor