HomeMy WebLinkAboutParental Consent Form (2)I_1aaIU_ TJII
STATE OF HAWAII )
CITY AND COUNTY OF HONOLULU )
being first duly sworn.
Deposes and says: [ ❑ I am ❑ we are] the [ ❑ father ❑ mother ❑ parents ❑ guardian(s)] of
born on
(FULL LEGAL NAME OF CHILD) (DATE OF BIRTH OF CHILD)
This affidavit has been made in connection with the desire of the aforesaid child to secure a license to drive;
❑ I am ❑ We are willing to assume the obligation imposed by Section 286- 112(b), HRS, "Any negligence or
misconduct of a minor under the age of eighteen years when driving a motor vehicle upon a highway shall be imputed to
the person who has signed the application of the minor for a permit, provisional license, or license, which person shall be
jointly and severally liable with the minor for any damages caused by the minor's negligence or misconduct."
Further Affiant sayeth naught.
Dated: City and County of Honolulu, Hawaii 120
SIGNATURE OF MOTHER/ GUARDIAN / LEGAL PARENT
PRINTED NAME
IDENTIFICATION PRESENTED
EXP. DATE
Subscribed and sworn before me this day
of 120
Notary Public
State of
My commission expires:
(Stamp or Seal)
CS- L -(DL) 239 (9/12) -mm
Judicial Circuit
SIGNATURE OF FATHER /GUARDIAN /LEGAL PARENT
PRINTED NAME
IDENTIFICATION PRESENTED EXP. DATE
SIGNATURE OF EXAMINER DATE
NOTARY CERTIFICATION:
(Hawaii Administrative Rules §5 -11 -8)
Document Date:
Document Description:
Notary Printed Name
Notary Signature
(Stamp or Seal)
No. Pages:
Circuit
Date