School Compliance Verification Form – Fill Out and Use This PDF

COMMONWEALTH OF KENTUCKY

School Compliance Verification: KRS 159.051

At the initial application for an original Kentucky learner’s permit or transfer license only, a 16-17 year old should submit to the local Circuit Court Clerk’s Office, one of the following documents: (1) proof of graduation from HS, or (2) proof of GED completion, or (3) a signed and *sealed School Compliance Verification: KRS 159.051 (obtained from the student’s school district of residence).

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 Transportation Cabinet 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 issued, my child must be compliant with KRS 159.051. Parent/Guardian Signature: ________________________________________________ Date: ________________________________

PUBLIC SCHOOL CERTIFICATION: Kentucky public school personnel should verify that this student is in compliance with KRS 159.051 (i.e., a 16 or 17 year old student shall be deemed compliant, if he/she has less than 9 unexcused absences and has passed 4 of 6 courses, or the equivalent, in the preceding semester).

District:Full Name of School: ________________________________________

School Telephone Number: (____)_______________

School Address: ____________________________________ ___________________________ _______________________ __________

	Street		City	County		Zip Code
	I hereby certify that this public school student is in compliance with KRS 159.051, as it relates to No Pass/No Drive.
	Designated Public School Representative:		/		/_____________________
		Signature	Print Name			Title
	Date: _______________________________________

PRIVATE SCHOOL CERTIFICATION (Includes Home Schools): School information to be completed by the

designated representative of the Kentucky private school/home school to certify their student’s compliance with KRS 159.051 (i.e., a 16 or 17 year old student shall be deemed compliant, if he/she has less than 9 unexcused absences and has passed 4 of 6 courses, or

the equivalent, in the preceding semester).
Full Name of School:	School Telephone Number: ( )__________________

School Address: ____________________________________ _____________________________ _________________ _____________

Street		City			County	Zip Code
I hereby certify that this private/home school student is in compliance with KRS 159.051, as it relates to No Pass/No Drive.
Private/Home School Representative:					/	_
	Signature			Print Name	Title
Date: _______________________________________

OUT-OF-STATE SCHOOL CERTIFICATION: To be completed by the out-of-state school representative to certify their Kentucky resident’s compliance with KRS 159.051 (i.e., a 16 or 17 year old student shall be deemed compliant, if he/she has less than 9 unexcused absences and has passed 4 of 6 courses, or the equivalent, in the preceding semester).

Full Name of School: _____________________________________________School Telephone Number: (___)___________________

School Address: _____________________________________ _____________________________ ___________________ _________

StreetCityCountyZip Code OOS School Representative: ________________________________ _______________________________ _____________________

Signature	Print Name	Title
DATE: ________________________________________

(Schools should keep a copy of this form for their records)

*Date: _____________________ (expires after 60 days) *This form is valid until _________________________

Revised 01/01/12(6) * Embossed seal required for all public/private schools (excludes home schools) on or after 01/01/2012