named above applied for a driver permit/license. You may do so by submitting a completed MV-1W (Withdrawal of Consent) to DMV.
By submitting the MV-1W, you will be canceling the applicant’s class DJ or MJ license/permit.
CERTIFICATION
I certify that I am the parent or guardian of the applicant named above. I also certify that the applicant has completed at least 50
hours of supervised driving, including 15 hours after sunset. I understand that some or all of the required supervised driving hours
may have been completed with a licensed driving school instructor or driver education teacher, and that these hours may be certified
on the reverse side of this form. I certify that any supervised driving hours that were not completed with a licensed driving school
instructor or driver education teacher were completed: 1) under the immediate supervision of a person at least 21 years of age who
holds a license that is valid in New York State to operate the type of vehicle that was used, and 2) in compliance with any regional
restrictions applicable to driving with a junior learner permit in that area. I understand that falsifying any information on this
certification may be a crime (felony or misdemeanor), punishable by a fine, imprisonment, or both.
