Form PPS-1118

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" height=90 BGCOLOR="#006699" TEXT="#080000" bgproperties="fixed" background="0a0285a1erlcgo.png"> <div> <FONT SIZE="5" COLOR="#FFFFFF" FACE="Times New Roman" ><B>H.E.A.R.T.H. Inc.</B></FONT><B>    </B><B> |     </B><A HREF="index.htm" TARGET="_top" TITLE="H.E.A.R.T.H. Inc."><U><B>home</B></U></A><B>     </B><A HREF="id101_drivers_license_procedures_for.htm" TARGET="_top" TITLE="Drivers License Procedures for Homeschoo"><U><B>     Driver's License Procedures</B></U></A><B>        </B><A HREF="id87.htm" TARGET="_top" TITLE="HEARTH Handbook"><U><B> HEARTH Handbook</B></U></A></div> <div> </div> </td> </tr><tr> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> PPS 1118 06/94</div> <bR> <DIV ALIGN="LEFT"></DIV> <div> PARENTAL CERTIFICATION OF CLASSROOM HOURS</div> <div> FOR DRIVER EDUCATION</div> <bR> <div> INSTRUCTIONS: This form is to be used by parents to certify that their child has spent a minimum of 36 clock hours completing a driver education course approved by the Virginia Department of Education for meeting the requirements of the classroom phase of the program.  The form must be completed and returned to the local school division superintendent with an official transcript from the correspondence school as evidence of satisfactory completion of the course.</div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="645" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="208"><div> Student's Name  </div> </tD> <tD VALIGN=TOP><NOBR><div> __________________________________________________</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="645" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="208"><div> Social Security No.</div> </tD> <tD VALIGN=TOP><NOBR><div> __________________________________________________</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="645" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="208"><div> Address </div> </tD> <tD VALIGN=TOP><NOBR><div> ___________________________________________________</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="645" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="208"><div> City, State, Zip Code </div> </tD> <tD VALIGN=TOP><NOBR><div> ___________________________________________________</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="645" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 16 ><NOBR><div> Name of Correspondence School </div> </NOBR></tD> <tD VALIGN=TOP><NOBR><div>  ___________________________________________________</div> </NOBR></tD> </tR> </TABLE></div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> ATTACH AN OFFICIAL TRANSCRIPT FROM THE SCHOOL</div> <bR> <bR> <div> By my signature below, I certify that the above-named student has completed at least 36 clock </div> <div> hours of instructional time while working toward the completion of the course and that I am the parent of the student.</div> <bR> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="646" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 16 ><NOBR><div> _________________</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="130"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="130" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP><NOBR><div> __________________________________________</div> </NOBR></tD> </tR> </TABLE></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="646" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="146"><div> Date</div> </tD> <tD VALIGN=TOP WIDTH="130"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="130" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="360"><div> Signature</div> </tD> </tR> </TABLE></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="646" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="146"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="146" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="130"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="130" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="360"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="360" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="646" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="146"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="146" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="130"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="130" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="360"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="360" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="646" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="146"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="146" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="130"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="130" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP><NOBR><div> __________________________________________</div> </NOBR></tD> </tR> </TABLE></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="646" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="146"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="146" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="130"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="130" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="360"><div> Print Name</div> </tD> </tR> </TABLE></div> <bR> <bR> <bR> <bR> </td> </tr></table></body>