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Today's Date: _______________
Road Test Date and Time:___________________________
Circle correct tester: Byron Anna
First Middle Last
Hm. Phone:(____)_________ Cell Phone:(____)_________
Driver License Number(1):____________________________
When did you get your WHITE Level 1 Graduated License? (This date should be at least 6 months before your road test date.)
_________________________________________________Segment 2 certificate number(2):______________________ Driver Education Code on white card(3):_________________ Segment 2 Completion Date(4):_______________________
Vehicle Year:________________ Make:________________
Model:_______________ Plate Number:________________
Car Insurance Company Name:_______________________
Insurance Expiration Date:___________________________
On the day of your test, please bring ALL supporting documents and certificates used to fill out this form so the information can be verified. Thank You!
Please note the following:
(1)The Driver License Number will be the single letter followed by 12 digits that is at the top middle of the Level 1 Graduated License, underneath the word, "Graduated". For example, M260345234567. On the Adult Temporary Permit, it is found under the word, "Temporary Instruction Permit".
(2) This red number will be in the top right corner of the Segment 2 certificate of completion white card. For example, X134234.
(3) This should be on the WHITE Segment 2 Driver Education certificate of completion certificate. It is usually a letter followed by a 2 digit number. For example, 212 or B12.
(4) This should be on the WHITE card received after completing the 6 hours of Segment 2 class work.
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