Minor’s Application for Driver’s License
The parent/guardian should
submit this form to the local Circuit Clerk’s Office at the initial
application only for a learner’s permit or transfer license, accompanied by
an original or certified copy of the student’s birth certificate and a signed
social security card.
STUDENT
INFORMATION:
Name: Last____________________________________
First ___________________________
Middle __________________________
(This section will be completed by a legal parent or guardian and then returned to the school with parent/guardian’s signature)
Date of Birth: Last Four Digits of Social Security
Number: XXX-XX-________________________ Month/Date/Year
PARENT/GUARDIAN CONSENT:
I hereby consent to the release of the above information to the KY Transportation Cabinet as set forth in KRS 159.051. I fully understand that in order for this form to be verified my child must be compliant with KRS 159.051.
Parent/Guardian Signature: ________________________________________________ Date: ________________________________
Signatures
should appear in blue ink
PUBLIC SCHOOL
CERTIFICATION: (School personnel will verify
that this student is in compliance with KRS 159.051) District:
Boone County
School Telephone Number: ( 859
) 334.4400
School
Address: 3310 Cougar Path
I hereby certify that this public school
student is in compliance with KRS 159.051.
Designated Public
School Representative: Mary Sargent / Assistant
Principal
Signature Print Name Title Signature should appear in blue ink
NON-PUBLIC SCHOOL
CERTIFICATION (Includes
Home Schools): (School
information and student compliance lines 1-2, to be completed by the designated
representative of non-public school; the designated public school district
contact must certify that the non-public school has notified the local district
of their enrollment on line 3)
1. Full Name of School: School
Telephone Number: ( ) School
Address:
Street City County Zip Code
2. I hereby certify that this non-public
student is in compliance with KRS 159.051.
Designated
Signature Print Name Title
3. I
hereby certify that this non-public school has notified the local public school
district of its student enrollment, in accordance with KRS 159.160, KRS
159.030.
Designated Public School District Contact:
__________________________________________________________/________________
Signature
Print Name Title
Signatures should
appear in blue ink
OUT-OF-STATE SCHOOL
CERTIFICATION: (line 1 to be completed by KY designated
district contact in district of residence, line 2 to be completed by designated
out-of-state school representative)
1. I hereby certify that my district has been
notified by the parent or school, that this student is attending an
out-of-state school in accordance with KRS 159.030 and KRS 159.160.
Designated KY public school district contact: / ____
Signature Print Name Title
2. I hereby certify that this
out-of-state student (OOS) is in compliance with KRS 159.051.
Signature Print Name Title
Signatures should appear in blue ink
Date: _______________________ This application form is valid for 60 days
until ______________________
Revised 5/30/08 (Schools
should keep a copy of this form for their records)