GEORGIA DEPARTMENT OF DRIVER SERVICES
APPLICATION FOR INMATE DRIVERS CERTIFICATE
PART I--DRIVER INFORMATION: (Please Print)
NAME _________________ CURRENT GA. LIC.# _____
(Last) (First) (Middle)
DATE OF BIRTH ________ SOC. SEC. # ____________
NAME OF CORRECTIONAL INSTITUTION ___________
ADDRESS _____________________________________
(P.O. Box) (Street) (City) (State) (Zip Code)
SIGNATURE ___________________ DATE ___________
NOTE--Your driving record will be checked. If you are under suspension or revocation this certificate will not be issued. All licenses in your possession must be surrendered upon issuance of Inmate Certificate. Each inmate requesting such certificate must pass all examinations (vision, written, and driving) required by law for the particular class of certificate applied for, unless successfully completed within sixty (60) days prior to application.
PART II--CERTIFICATION BY WARDEN OR SUPERINTENDENT
I hereby certify the above named person to be an inmate of said Institution. I realize that I may cancel the certificate at any time. Further, I affirm that I will receive from the inmate and return to the Department of Driver Services such certificate upon the inmate's transfer, parole, pardon, or release.
SIGNED _______________________________________
TITLE ________________________________________
DATE ___________________
PART III--CANCELLATION OF INMATE DRIVER'S CERTIFICATE
NAME OF INMATE _______________________________
CERTIFICATE NUMBER __________________________
DATE OF BIRTH _______ SOC. SEC. # ___________
NAME OF CORRECTIONAL INSTITUTION _____________
ADDRESS _____________________________________
(P.O. Box) (Street) (City) (State) (Zip Code)
This will certify that the inmate named herein is no longer the holder of such driver's certificate issued on (Date) ________ due to: (Check one)
____ Cancellation
____ Parole
____ Transfer
____ Release
____ Pardon
____ Other (Specify)
Such certificate number ____________________ is enclosed.
SIGNED ______________________________________
TITLE _______________________________________
DATE ____________________
Mail this certification form and certificate to Department of Driver Services, P. O. Box 80447, Conyers, Georgia 30013.
Ga. Comp. R. & Regs. R. 125-2-4-.13
Ga. Constitution 1983, Art. XI, Sec. I, O.C.G.A. Secs. 42-2-11, 42-3-3, 42-5-24, 42-5-52, 42-5-53, 42-5-55, 42-10-2.