New York State Department of Motor Vehicles CERTIFICATION OF 20 HOURS OF SUPERVISED DRIVING Driver license applicants who have a junior learner permit (DJ or MJ) issued on or after September 1, 2003 must present this completed certificate to the Motor Vehicles License Examiner at the road test. This requirement does not apply to 17-year old permit holders who have completed a certified Driver Education course and who present a valid Student Certificate of Completion (MV-285) at the road test, since they will be issued a senior license (Class D or M) upon passage of the road test. License Applicant Name ___________________________________________________________ID Number ________________________ Address __________________________________________________________________________________________________ __________________________________________________________________________________________________ NOTE to parent/guardian of junior driver(s): You have the right to withdraw the consent you granted when the junior driver named above applied for a driver permit/license. You may do so by returning a completed MV-1W (Withdrawal of Consent). By returning the MV-1W, you will be canceling the applicant’s class DJ or MJ license/permit. CERTIFICATION I certify that I am the parent or guardian of the applicant named above. I also certify that the applicant has completed at least 20 hours of supervised driving. Any supervised driving hours that are not certified on this form by a licensed driving school instructor/owner or driver education instructor/administrator have been completed: 1) under the immediate supervision of a person at least 21 years of age who holds a license that is valid in New York State to operate the type of vehicle that was used, and 2) in compliance with any regional restrictions applicable to driving with a junior learner permit in that area. I understand that falsifying any information on this certification is a violation of Section 392 of the Vehicle and Traffic Law, and is punishable as a misdemeanor. Printed Name of Parent or Guardian __________________________________________________________________________________________ Parent/Guardian Signature ___________________________________________________________ Date ________________________________ ± Name of Driving School or Name of School Conducting Driver Ed Program School License Number Instructor’s Name Instructor Certificate Number Number of Hours Certified Administrator or Owner or Instructor’s Signature Any information provided above must be supported by records required pursuant to the Regulations of the Commissioner of the Departments of Motor Vehicles and Education. Any false statement is a violation of Section 392 of the Vehicle and Traffic Law, and is punishable as a misdemeanor. MV-262 (7/07) www.nysdmv.com American LegalNet, Inc. www.FormsWorkFlow.com