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Texas Defensive Driving Student Affidavit

Attention Student:
Your record was unable to be verified by TEA-approved thirdparty database sources. To receive credit for course completion, you must complete the Student Affidavit form on the next page. To complete the affidavit:

1. Print the attached form.
2. Using transparent tape, attach your license to the form face-up. 3. Photocopy the form.
4. Clearly print the information on the top half of the form.
5. In the presence of a notary, sign and date the photocopied form.
Mail the photocopied form to:
American Safety Council, Inc.
5215 Adanson St., Suite 500
Orlando, Florida 32804
Phone: 877-463-2477
Fax: 855-899-4183

Copyright 2014, American Safety Council, Inc. All Rights Reserved.

Texas Education Agency
Division of Driver Training

STUDENT AFFIDAVIT
I,

,

,

Legal Name (printed or typed)

Mailing Address

,

,

City

State

,
ZIP Code

,
Driver's License Number (if applicable)

,
COPY PICTURE ID HERE

State Issuing Driver's License

make the following Statement:
I have read and accepted the school's Student Enrollment Contract and Terms of Agreement for

American Safety Council, Inc. / American Safety Council - Texas Safe Motorist Course
Name of Course Provider/Course

I am currently enrolled and personally attending the afore-mentioned six-hour driving safety course in accordance with the policies and procedures of the course. I did not receive any assistance to complete this course other than assistance from the school's technical support staff or instructors. I have not attempted to misrepresent my identification in any way while taking this driving safety course. A copy of my driver’s license or equivalent type of photo identification is shown on this page.

Signature

STATE OF

COUNTY OF

Personally appeared before me, the above-named
, known to me, who provided the document copied above, and who being duly sworn, deposes and says that she/he executed this affidavit and that the statements and representations contained therein are true and correct to the best of her/his knowledge and belief.
SUBSCRIBED AND SWORN before me this

day of

, 200

Notary Public (signature)

SEAL
COMMISSION EXPIRES:
DT-SA (Rev. 05/27/2014)