DL-180C (3-16)
PARENT OR GUARDIAN
CERTIFICATION FORM
(PRINT NAME OF MINOR)
(LEARNER'S PERMIT NUMBER)
I hereby certify that this minor applicant has completed at least 65 hours of supervised practical
driving experience, including (except for a motorcycle permit applicant *) 10 hours of nighttime
driving and 5 hours of inclement weather driving. This behind-the-wheel experience was given by a
licensed driver(s) 21 years of age or older.
* Completion of a Pennsylvania Motorcycle Safety Program basic rider course is required for
motorcycle permit applicants in lieu of the 10 hours of nighttime driving and 5 hours of inclement
weather driving and counts toward the 65-hour requirement.
SIGN IN PRESENCE OF NOTARY, DRIVER LICENSE EXAMINER, END-OF-COURSE SKILL TEST
TEACHER, CERTIFIED THIRD PARTY EXAMINER, OR MOTORCYCLE SAFETY INSTRUCTOR
X
(signature
of parent , guardian , person in loco parentis or spouse at least
18
years of age )
X
(print
Notarized Signature
required ONLY if
parent or guardian is
not accompanying the
teen driver to the
Driver License Center
for their Skills Test.
name as it appears in signature )
SUBSCRIBED AND SWORN
TO BEFORE ME: MO. DAY YEAR
Signature of Person Administering Oath
S
E
A
L
SIGN IN PRESENCE OF NOTARY
OR
DRIVER LICENSE EXAMINER
EXAM CENTER EXAMINER #
OR
INSTRUCTOR #