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Student Information
Name
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First
Last
Student 1st Middle Name
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Student 2nd Middle Name
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Student Date of Birth
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Gender
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Male
Female
Student Email
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Student Phone Number
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Student Home Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Parent 1 Information
Name
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First
Last
Parent Email
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Parent Cell Number
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Parent Home Number
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Parent 2 Information
Name
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First
Last
Email
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Cell Number
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Home Number
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DE99 - Driver's Education Permit & Completion Certificate
The following are medical, vision and license questions for the DE99 form, which is issued by the Kansas Department of Revenue, and used as a driving permit. It will also serve as a certificate of completion for the Driver's License Exam Bureau.
Eye Color
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Height: Feet
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4
5
6
Inches
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1
2
3
4
5
6
7
8
9
10
11
Weight in lbs
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Do you need vision correction, wear glasses or contacts?
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Yes
No
Are you a Kansas Resident?
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Yes
No
In the last 6 months, have you attempted and failed any testing at least 4 times at the Kansas Driver's License Exam Station?
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Yes
No
If yes, last test date?
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Do you have any physical limitations that may require car modifications?
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Yes
No
If yes, please name car modifications needed:
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Do you currently have any physical, medical, vision or mental condition(s) that could make it difficult to operate a motor vehicle safely? (not including glasses)
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Yes
No
If yes, please name:
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Have you suffered a seizure in the last 6 months?
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Yes
No
If yes, please describe and date
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Are you currently enrolled in drug rehabilitation or a habitual user of drugs or alcohol?
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Yes
No
If yes, please describe program:
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Do you have a current or expired Kansas driver license, instructional permit or ID?
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Yes
No
Current or expired ID, License or Instructional Permit No.
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Expiration Date
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Is your license now or has it ever been suspended/restricted/revoked in Kansas or any other state?
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Yes
No
If yes, give date
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Reason
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Has your license/permit been surrendered to law enforcement due to the refusal or failure of a chemical test for drugs or alcohol?
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Yes
No
If yes, reason surrendered:
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Is your license/permit suspended/canceled/revoked by any court pending review?
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Yes
No
If yes, describe pending court review:
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