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OF PERMIT HOLDER: TENN PERMIT NUMBER: STREET ADDRESS CITY NAME OF PARENT, GUARDIAN OR LICENSED INSTRUCTOR: ADDRESS SOCIAL SECURITY NUMBER: STATE ZIP CODE DRIVER LICENSE NUMBER: CITY SOCIAL SECURITY NUMBER: STATE ZIP CODE I affirm that I am the above named parent/guardian or licensed instructor, and I certify that the above named permit holder (under the age of 18) has completed fifty (50) hours of behind the wheel driving including a minimum of ten (10) ho.

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