Texas Department of Licensing and Regulation
STUDENT AFFIDAVIT
Once complete, please email a scan or photo of the affidavit and ID to
documents@nationalsafetycommission.com for review.
I, , ,
Legal Name (printed or typed) Mailing Address
, , ,
City State ZIP Code
,
Driver's License Number (if applicable)
,
State Issuing Driver's License COPY PICTURE ID HERE
make the following Statement:
I have read and accepted the SafeDriver.com's Student Enrollment Contract and Terms of Agreement for
their “Aware Driver Course.” I personally attended and completed or am planning on attending and
completing 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
ORIGINAL EMAILED/FAXED ON
Date
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 , 20
Notary Public (signature)
SEAL
COMMISSION EXPIRES:
INSTRUCTIONS TO COMPLETE AND PROVIDE YOUR AFFIDAVIT TO
THE COURSE PROVIDER
Complete the following fields on the affidavit
● Legal Name (printed or typed)
● Mailing Address
● City
● State
● Zip code
● Drivers License Number (if applicable)
● State Issuing Drivers License
Make a photocopy of your drivers license or picture ID and affix it to the form in the
square that states COPY PICTURE ID HERE.
● Present the form to a Notary and present your ID to them. (Most banks have a
notary on site during business hours or you can look for a notary in your local
yellow pages)
● In the presence of the notary, sign the form and add the State and County in the
spaces provided.
● The notary will review your ID and notarize the form by signing the form
themselves and placing an official notary stamp on the form. Please make sure
the stamp is bold and clear.
● Email a clear photo or scanned copy of your notarized affidavit to us at
documents@NationalSafetyCommission.com.
Please note that it is no longer necessary to mail the original affidavit to us if you
have successfully emailed the document to us per the instruction above.
However, we suggest keeping the original on file for your records.
Remember, you will not be able to finish the course until we receive your affidavit.
