Road Test Application

Today’s Date: ____________Road Test Date & Time:________________
Circle correct examiner:              Byron               Anna
___________________________________________________________________Name:First                               Middle                 Last
Birth Date:_______/_______/________                  
Hm. Phone:(_____)_____________  Cell Phone:(_____)_____________
E-mail address:______________________@___________________________
Driver License Number(1):_______________________________________When did you get your WHITE Level 1 Graduated License? (This date should be at least 6 months before your road test date.)___________________________________________________________________

Segment 2 certificate number(2):________________________________

Driver Education Code on white card(3):________________________

Segment 2 Completion Date(4):__________________________________

Vehicle Year:________________ Make:_______________________________

Model:_______________ Plate Number:______________________________

Car Insurance Company Name:___________________________________

Insurance Expiration Date:________________________________________

On the day of your test, please bring ALL supporting documents and certificates used to fill out this form so the information can be verified. Thank You!

Please note the following: 

(1) The Driver License Number will be the single letter followed by 12 digits that is at the top middle of the Level 1 Graduated License, underneath the word, “Graduated”. For example, M260345234567. On the Adult Temporary Permit, it is found under the word, “Temporary Instruction Permit”.
(2) This red number will be in the top right corner of the Segment 2 certificate of completion white card. For example, X134234.
(3) This should be on the WHITE Segment 2 Driver Education certificate of completion certificate. It is usually a letter followed by a 2 digit number. For example, 212 or B12.
 This should be on the WHITE card received after completing the 6 hours of Segment 2 class work.
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