Form Si-59 - Application For Student Instructor Permit (Page 2 of 2) in pdf

Form Si-59 - Application For Student Instructor Permit Page 2

(page 2 of 2)

SCHOOL AFFIDAVIT

I certify that I am an agent of the aforementioned school and that the named applicant is being registered within five (5)

days of beginning his/her instructor training. I further certify that I have read and will abide by those laws and rules

governing the training and supervision of the named applicant.

______________________________________________________

Signature of school agent

State of ______________, County of _________________, ss.

Subscribed and sworn before me this ______ day of _______________________, 20 _____.

______________________________________________________

(seal)

Notary Public official signature

residing at_____________________________________________

my commission expires___________________________________

SI-59-revised 08/00

Form Si-59 - Application For Student Instructor Permit Page 2