I, _______ _____, hereby make the following Assurances to and the Driver Training Division of the Texas Education Agency:
  1. My date of birth is ______________________________________.
  2. I have not attempted to misrepresent my identification in any way to while attempting to take the Internet course.
  3. I have not attempted to circumvent the Security and Validation Policy of the Internet driving safety course.
  4. I have read and accepted the Course Contract and accept the Terms and Conditions.
  5. I have and will be personally completing the Internet driving safety course without assistance from any other person, except as necessary from DDO staff or personnel.
  6. I understand that if I attempt to circumvent the Security and Validation Policy of, I will be committing perjury and other criminal acts which may be punishable by a maximum of 10 years in prison and a $10,000 fine, in addition to possible civil penalties.

_____________________________________________ (Student Signature)

Before me, the undersigned authority, on this day personally appeared:
_____________________________________________ known to me to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he/she signed the same for the purpose and consideration therein expressed.

Given under my hand and seal of office, on the _______ of __________________, 20____.

Signature of Notary Public

in and for the State of ___________.

IMPORTANT: State regulations require that you submit the Statement of Assurance no later than 15 days after completing the final exam. If you send your Statement of Assurance after 15 days from the date you complete the exam, your completion date that is printed on your Certificate of Completion will change to the date your form is received.
Please return notarized Statement of Assurance:
via facsimile: (713) 488-4102
via mail: 11 Greenway Plaza, Ste 3150, Houston, TX 77046

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