DL WID FORM

(PRINT NAME OF APPLICANT)

DL-180TD (2-19) PARENT OR GUARDIAN CONSENT FORM i i ' P g P l P S, i 18 . i : (C ) t . i i the 18, Pdot ' . i understand i will be required to ensure this applicant will have to complete at least 65 hours of-- - and five (5) hours of bad weather driving, before they will be permitted to take the driver's test. the

Parent/Guardian consent for use with DL-180 for under 18 years of age (DL-180TD)

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DL-180td
DL-180TD (2-19)
PARENT OR GUARDIAN CONSENT FORM

(PRINT NAME OF APPLICANT)
i hereby certify that i am the minor applicant's  Parent  guardian  Person in loco Parentis or  Spouse, and i am at least 18 years of age.
i also certify: (Check all that apply)
 this application is made with my full consent.
 i understand if i want to withdraw my consent at any time before this minor applicant reaches the
age of 18, Penndot will cancel their driver's license.
 i understand i will be required to ensure this applicant will have to complete at least 65 hours of
supervised behind-the-wheel skill-building including no less than ten hours of nighttime driving and five (5) hours of bad weather driving, before they will be permitted to take the driver's test. the supervising adult must be at least 21 years of age or older.
 i understand Penndot recommends the supervising adult refer to the Parent's Supervised driving
Program guidebook when teaching the minor applicant how to drive.
Pennsylvania strongly supports organ and tissue donation because of its life-saving and life-enhancing opportunities.
i  DO  DO NOT give consent for the applicant's request for organ donor designation.

AUTHORIZATION AND CERTIFICATION Parent or Guardian: Sign this form onlY in the presence of a notary or the driver's license examiner at the driver license Center. i hereby certify under penalty of law that this information contained herein is true and correct. warning: Misstatement of fact is a misdemeanor of the third degree punishable by a fine of up to $2,500 and/or imprisonment up to 1 year (18 Pa. C.S. Section 4904[b]).
XSIGN
HERE
(SIGNATURE OF PARENT, GUARDIAN, PERSON IN LOCO PARENTIS OR SPOUSE AT LEAST 18 YEARS OF AGE)

(PRINT NAME AS IT APPEARS IN SIGNATURE)
Address: ________________________________ City: ____________________________________ State:_________ Zip:________________
(LICENSE NUMBER OF PARENT, GUARDIAN, PERSON IN LOCO PARENTIS OR SPOUSE, IF APPLICABLE)

SubSCribed And Sworn

to before Me:  

Mo.

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Signature of Person Administering oath

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Sign in PreSenCe of notArY or

A

driver liCenSe exAMiner

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