Get In State Form 54706 2013

Reset Form LOG OF SUPERVISED DRIVING PRACTICE State Form 54706 R4 / 7-17 INDIANA BUREAU OF MOTOR VEHICLES INSTRUCTIONS 1. Complete in blue or black ink or print form* 2. Completed hours/minutes must be entered on the approved log s. Multiple logs may be completed and attached if necessary. 3. Must present completed log s upon application for license. SECTION 1. DRIVING LOG Driver Name last first middle initial Bioptic Drivers Only - Please Check Here Driver s License Number DLN Drive Time Hours / Minutes DATE mm/dd/yyyy DAY NIGHT CONTINUED ON BACK. SECTION 2. AFFIRMATION AND SIGNATURE I certify that the driver named above has completed fifty 50 hours of supervised driving practice ten 10 of which included nighttime driving practice with a licensed driver education instructor who was working under the direction of a driver training school a certified driver rehabilitation specialist recognized by the bureau who is employed through a driver rehabilitation program a validly licensed driver at least twenty-five 25 years of age who is related by blood marriage or legal status Services or Applicants under eighteen 18 years of age must have a parent or guardian sign below. If eighteen 18 years of age or older only the driver must sign below. I swear or affirm that the information entered on this form is true and correct. I understand that making a false statement may constitute the crime of perjury. Signature of Parent or Legal Guardian if Applicant is under eighteen 18 years of age Signature of Applicant Printed Name. Complete in blue or black ink or print form* 2. Completed hours/minutes must be entered on the approved log s. Multiple logs may be completed and attached if necessary. 3. Must present completed log s upon application for license. Multiple logs may be completed and attached if necessary. 3. Must present completed log s upon application for license. SECTION 1. DRIVING LOG Driver Name last first middle initial Bioptic Drivers Only - Please Check Here Driver s License Number DLN Drive Time Hours / Minutes DATE mm/dd/yyyy DAY NIGHT CONTINUED ON BACK. SECTION 1. DRIVING LOG Driver Name last first middle initial Bioptic Drivers Only - Please Check Here Driver s License Number DLN Drive Time Hours / Minutes DATE mm/dd/yyyy DAY NIGHT CONTINUED ON BACK. SECTION 2. AFFIRMATION AND SIGNATURE I certify that the driver named above has completed fifty 50 hours of supervised driving practice ten 10 of which included nighttime driving practice with a licensed driver education instructor who was working under the direction of a driver training school a certified driver rehabilitation specialist recognized by the bureau who is employed through a driver rehabilitation program a validly licensed driver at least twenty-five 25 years of age who is related by blood marriage or legal status Services or Applicants under eighteen 18 years of age must have a parent or guardian sign below. SECTION 2. AFFIRMATION AND SIGNATURE I certify that the driver named above has completed fifty 50 hours of supervised driving practice ten 10 of which included nighttime driving practice with a licensed driver education instructor who was working under the direction of a driver training school a certified driver rehabilitation specialist recognized by the bureau who is employed through a driver rehabilitation program a validly licensed driver at least twenty-five 25 years of age who is related by blood marriage or legal status Services or Applicants under eighteen 18 years of age must have a parent or guardian sign below. If eighteen 18 years of age or older only the driver must sign below. I swear or affirm that the information entered on this form is true and correct. .