COMMONWEALTH OF KENTUCKY

SCHOOL COMPLIANCE VERIFICATION FOR DRIVER LICENSING

KRS 159.051 (NO PASS/NO DRIVE STATUTE)

A legal parent or guardian must complete and sign the student information section. Please return form with parent/guardian signature to the school. School personnel will verify that this student is in compliance with KRS 159.051. Home school and out-of-state students must have the last section completed/certified by the Public School District Director of Pupil Personnel of residence.

STUDENT INFORMATION (to be completed by parent)

Name: Date of Birth:

Last First Middle Month/Date/Year

Last Four Digits of Social Security Number: XXX-XX-

PARENT/GUARDIAN CONSENT

I hereby consent to the release of the above information to the Department of Transportation as set forth in KRS 159.051 as it relates to No Pass/No Drive. 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: ______________________________

KY PUBLIC AND (In-state) PRIVATE/HOME SCHOOL INFORMATION (to be completed by school)

District: BOONE COUNTY Full Name of School: CONNER HIGH SCHOOL

School Telephone Number: ( 859 ) 334.4400 School Address:

PO Box

3310 COUGAR PATH HEBRON BOONE 41048

Street City County Zip Code

SCHOOL CERTIFICATION

I hereby certify that this student is in compliance with KRS 159.051.

Designated School Representative: MARY SARGENT

Signature Print Name

Date: ___________________________________________ (This verification form is invalid sixty (60) days from this date.)

or Private School:

Signature of Principal Print Name

AFFIX SCHOOL SEAL (Please affix school seal)

HOME SCHOOL AND OUT-OF-STATE SCHOOL CERTIFICATION (to be completed by DPP)

I hereby certify that this home school or out-of-state school and student are registered and in compliance with 601 KAR 13:070.

Public School District Director of Pupil Personnel:

Signature Print Name

Date: ___________________________________________ (This verification form is invalid sixty (60) days from this date.)

To apply for a driver’s license, submit the completed form to the Circuit Clerk's Office with the following documents: an original or certified copy of the student’s birth certificate and signed social security card. Additionally, a parent or legal guardian must be present to give his/her consent.

Revised 8/2007