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Fillable Printable Application for a Non-Commercial Learner Permit And/Or Driver License - Connecticut
Fillable Printable Application for a Non-Commercial Learner Permit And/Or Driver License - Connecticut
Application for a Non-Commercial Learner Permit And/Or Driver License - Connecticut
DMV USE
ONLY
NEW
OUT OF STATE
TRANSFER
RETEST
CHANGE ENDORSEMENT/
RESTRICTION
EXCHANGE
APPLICATION FOR A NON-COMMERCIAL
LEARNER PERMIT AND/OR DRIVER LICENSE
R-229 REV. 7-2013
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
On The Web At ct.gov/dmv
LEARNER PERMIT NUMBER DATE OF ISSUE
APPLICANT'S NAME (Last, First, Middle, Suffix)
2. SEX 3. DATE OF BIRTH
4. HEIGHT 5. COLOR OF EYES
ft. in.
MAILING ADDRESS (No., Street, City or Town, State, Zip Code) 7. RESIDENCE ADDRESS (If different)
12. LIST ANY OTHER NAMES EVER USED (Alias, Maiden, etc)
QUESTIONS
YES ( ) NO ( )
Have you previously failed a driver's license
examination in Connecticut?
Do you now hold or have you ever held an operator's license or
identification card from another state?
16.
FAILED
STATE, DRIVER LICENSE OR ID. NO. NO. OF YEARS
IN WHAT STATE(S)?
Do you now, or have you ever held a Connecticut Learner Permit,
License or Non-Driver Identification card?
IF YES, IN WHAT YEAR(S)? CONNECTICUT PERMIT, LICENSE OR ID NO. (9 digits)
MEDICAL
CERTIFICATION
I hereby certify that I do not
have any health or vision
problems or conditions that
prevent me from driving safely.
DO NOT WRITE BELOW THIS LINE - OFFICE USE ONLY
PROOF OF
IDENTIFICATION
TYPE OF ACCEPTABLE I.D. SHOWN
The information provided to the Commissioner of Motor Vehicles herein is
subscribed by me, under penalty of false statement, in accordance with
the provisions of Section 14-110 and 53a-157b of the Connecticut General
Statutes. I understand that if I make a statement which I do not believe to
be true, with the intent to mislead the Commissioner, I will be subject to
prosecution under the above-cited laws.
SIGNATURE OF APPLICANT
X
DATE SIGNED
VISION
SCREENING
RESULTS
VISUAL AID USED
NONE GLASSES/CONTACTS
RESULTS
PASSED FAILED
KNOWLEDGE
TEST
COMPUTER WRITTEN ORAL
TEST RESULTS
WAIVED
PASSED FAILED
PERMIT ISSUE MOTORCYCLE PERMIT
AGENT
CERTIFICATION
I hereby certify that I have examined the applicant's identity
documents and the test results stated herein are true and
correct.
SIGNED (Agent) DATE SIGNED
X
CLASSROOM
INSTRUCTION
SCHOOL NAME COMMERCIAL SCHOOL LICENSE NO. DRIVER EDUCATION CERTIFICATE NO.
PRACTICE
DRIVING
SCHOOL NAME (If same as above print "same") COMMERCIAL SCHOOL LICENSE NO. DRIVER EDUCATION CERTIFICATE NO.
I hereby subscribe and certify under penalty of false statement, in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes that I
understand that if I make a statement, which I do not believe to be true, with the intent to mislead the Commissioner I will be subject to prosecution under the above-cited laws, that,
I am qualified under Section 14-36, of the Connecticut General Statutes, over 20 years of age, have no suspensions within the previous 4 years and the Applicant has received the
required training, including the equivalent of 22 hours classroom training; 40 hours on-the-road instruction; the 8 hours Safe Driver course, including a 2 hour Parent Training, as
supported by a parent log and/or driving school certificate.
SIGNATURE OF INSTRUCTOR (Home Training/Commercial)
X
ROAD TEST
AND LICENSE
INFORMATION
WAIVED PASSED FAILED
NO FEE
U.S.
SERVICE
SPECIAL EQUIPMENT
NON-COMMERCIAL CLASS ENDORSEMENT RESTRICTIONS (Circle All Applicable)
D
M
Q
B C D E F G R U
I hereby certify that I have verified the applicant's
identity and the test results stated herein are true
and correct.
DISTRIBUTION: White - Branch Office Canary - Agent Pink - Examiner
SIGNED (Agent)
DATE SIGNED
1.
6.
8.
M F
Yes No
Yes No
HOME
TRAINING/
COMMERCIAL
TRAINING
CERTIFICATION
DRIVER
TRAINING
US CITIZEN? 9.
If "NO", list ALIEN REGISTRATION NO. CONNECTICUT
RESIDENT?
DO YOU WANT TO BE IN THE ORGAN/TISSUE DONOR
REGISTRY?
Yes No
If yes, you are agreeing to be a donor
and the designation will be on your
license.
10.
DAYTIME PHONE NO.
( )
Is your privilege to operate a motor vehicle suspended or subject to
suspension in Connecticut or in any other state?
1
Home Training
22 hr class equiv
40 hr on-the-road
8 hr safe driving
2
Comm/Sec and Home
30 hrs class/minimum
8 hr safe driving plus home
training 40 hrs on-the-road
3
Comm/Sec Only
30 hrs class
40 hrs on-the-road
LOCATION/DATE
OPERATOR LICENSE NUMBER OR
SCHOOL LICENSE NUMBER
I.D. SCANNED FIRST VISIT
EXAMINER INITIAL
STAMP NO.
PUNCH NO. AND PUNCH
AGENT
CERTIFICATION
PUNCH NO. AND PUNCH
Required Identification Documents & Proof of Connecticut
Residency: see "Acceptable Forms of ID" at ct.gov/dmv
16 and 17 year olds: Certificate of Parental Consent Form 2D
(if not accompanied by authorized individual)
Applicable Fees
KNOWLEDGE
VISION
ROAD SKILLS
CERTIFICATION
BY APPLICANT
PARENTAL
CONSENT
AGE 16 OR 17 ONLY
I hereby request that a learner's permit
and/or license be issued to the minor
filing this application.
RELATIONSHIP TO MINOR SIGNED (Authorized Consenter)
CONSENTER'S LIC. NO. OR OTHER I.D.
X
ISSUE LEARNER PERMIT
AGENTS INITIALS
PUNCH NO. AND PUNCH
INSTRUCTIONS: Complete 1-16, then present
1.
2.
3.
11. SOCIAL SECURITY NUMBER
14.
13.
15.
FULL LEGAL
NAME
If different than entered in name section above (# 1)
IDENTIFICATION DOCUMENTS
RETURNED
APPLICANT INITIALS
ISSUE PERMIT WITH CORRECTIVE LENSES
(B-RESTRICTION)
Section 14-36l of the Connecticut General Statutes requires the Commissioner to transmit my
information to the Selective Service System. By signing and submitting this application, I consent
to be registered with the Selective Service System, provided I am at least age 16 but under age
26 and meet the criteria for registration in accordance with the Military Selective Service Act. If I
am under age 18, I understand that my information will be transmitted to Selective Service but I
will not be registered until I reach age 18.
SELECTIVE
SERVICE
CONSENT
DMV USE
ONLY
NEW
OUT OF STATE
TRANSFER
RETEST
CHANGE ENDORSEMENT/
RESTRICTION
EXCHANGE
APPLICATION FOR A NON-COMMERCIAL
LEARNER PERMIT AND/OR DRIVER LICENSE
R-229 REV. 7-2013
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
On The Web At ct.gov/dmv
LEARNER PERMIT NUMBER DATE OF ISSUE
APPLICANT'S NAME (Last, First, Middle, Suffix)
2. SEX 3. DATE OF BIRTH
4. HEIGHT 5. COLOR OF EYES
ft. in.
MAILING ADDRESS (No., Street, City or Town, State, Zip Code) 7. RESIDENCE ADDRESS (If different)
12. LIST ANY OTHER NAMES EVER USED (Alias, Maiden, etc)
QUESTIONS
YES ( ) NO ( )
Have you previously failed a driver's license
examination in Connecticut?
Do you now hold or have you ever held an operator's license or
identification card from another state?
16.
FAILED
STATE, DRIVER LICENSE OR ID. NO. NO. OF YEARS
IN WHAT STATE(S)?
Do you now, or have you ever held a Connecticut Learner Permit,
License or Non-Driver Identification card?
IF YES, IN WHAT YEAR(S)? CONNECTICUT PERMIT, LICENSE OR ID NO. (9 digits)
MEDICAL
CERTIFICATION
I hereby certify that I do not
have any health or vision
problems or conditions that
prevent me from driving safely.
DO NOT WRITE BELOW THIS LINE - OFFICE USE ONLY
PROOF OF
IDENTIFICATION
TYPE OF ACCEPTABLE I.D. SHOWN
The information provided to the Commissioner of Motor Vehicles herein is
subscribed by me, under penalty of false statement, in accordance with
the provisions of Section 14-110 and 53a-157b of the Connecticut General
Statutes. I understand that if I make a statement which I do not believe to
be true, with the intent to mislead the Commissioner, I will be subject to
prosecution under the above-cited laws.
SIGNATURE OF APPLICANT
X
DATE SIGNED
VISION
SCREENING
RESULTS
VISUAL AID USED
NONE GLASSES/CONTACTS
RESULTS
PASSED FAILED
KNOWLEDGE
TEST
COMPUTER WRITTEN ORAL
TEST RESULTS
WAIVED
PASSED FAILED
PERMIT ISSUE MOTORCYCLE PERMIT
AGENT
CERTIFICATION
I hereby certify that I have examined the applicant's identity
documents and the test results stated herein are true and
correct.
SIGNED (Agent) DATE SIGNED
X
CLASSROOM
INSTRUCTION
SCHOOL NAME COMMERCIAL SCHOOL LICENSE NO. DRIVER EDUCATION CERTIFICATE NO.
PRACTICE
DRIVING
SCHOOL NAME (If same as above print "same") COMMERCIAL SCHOOL LICENSE NO. DRIVER EDUCATION CERTIFICATE NO.
I hereby subscribe and certify under penalty of false statement, in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes that I
understand that if I make a statement, which I do not believe to be true, with the intent to mislead the Commissioner I will be subject to prosecution under the above-cited laws, that,
I am qualified under Section 14-36, of the Connecticut General Statutes, over 20 years of age, have no suspensions within the previous 4 years and the Applicant has received the
required training, including the equivalent of 22 hours classroom training; 40 hours on-the-road instruction; the 8 hours Safe Driver course, including a 2 hour Parent Training, as
supported by a parent log and/or driving school certificate.
SIGNATURE OF INSTRUCTOR (Home Training/Commercial)
X
ROAD TEST
AND LICENSE
INFORMATION
WAIVED PASSED FAILED
NO FEE
U.S.
SERVICE
SPECIAL EQUIPMENT
NON-COMMERCIAL CLASS ENDORSEMENT RESTRICTIONS (Circle All Applicable)
D
M
Q
B C D E F G R U
I hereby certify that I have verified the applicant's
identity and the test results stated herein are true
and correct.
DISTRIBUTION: White - Branch Office Canary - Agent Pink - Examiner
SIGNED (Agent)
DATE SIGNED
1.
6.
8.
M F
Yes No
Yes No
HOME
TRAINING/
COMMERCIAL
TRAINING
CERTIFICATION
DRIVER
TRAINING
US CITIZEN? 9.
If "NO", list ALIEN REGISTRATION NO. CONNECTICUT
RESIDENT?
DO YOU WANT TO BE IN THE ORGAN/TISSUE DONOR
REGISTRY?
Yes No
If yes, you are agreeing to be a donor
and the designation will be on your
license.
10.
DAYTIME PHONE NO.
( )
Is your privilege to operate a motor vehicle suspended or subject to
suspension in Connecticut or in any other state?
1
Home Training
22 hr class equiv
40 hr on-the-road
8 hr safe driving
2
Comm/Sec and Home
30 hrs class/minimum
8 hr safe driving plus home
training 40 hrs on-the-road
3
Comm/Sec Only
30 hrs class
40 hrs on-the-road
LOCATION/DATE
OPERATOR LICENSE NUMBER OR
SCHOOL LICENSE NUMBER
I.D. SCANNED FIRST VISIT
EXAMINER INITIAL
STAMP NO.
PUNCH NO. AND PUNCH
AGENT
CERTIFICATION
PUNCH NO. AND PUNCH
Required Identification Documents & Proof of Connecticut
Residency: see "Acceptable Forms of ID" at ct.gov/dmv
16 and 17 year olds: Certificate of Parental Consent Form 2D
(if not accompanied by authorized individual)
Applicable Fees
KNOWLEDGE
VISION
ROAD SKILLS
CERTIFICATION
BY APPLICANT
PARENTAL
CONSENT
AGE 16 OR 17 ONLY
I hereby request that a learner's permit
and/or license be issued to the minor
filing this application.
RELATIONSHIP TO MINOR SIGNED (Authorized Consenter)
CONSENTER'S LIC. NO. OR OTHER I.D.
X
ISSUE LEARNER PERMIT
AGENTS INITIALS
PUNCH NO. AND PUNCH
INSTRUCTIONS: Complete 1-16, then present
1.
2.
3.
14.
13.
15.
FULL LEGAL
NAME
If different than entered in name section above (# 1)
IDENTIFICATION DOCUMENTS
RETURNED
APPLICANT INITIALS
ISSUE PERMIT WITH CORRECTIVE LENSES
(B-RESTRICTION)
Section 14-36l of the Connecticut General Statutes requires the Commissioner to transmit my
information to the Selective Service System. By signing and submitting this application, I consent
to be registered with the Selective Service System, provided I am at least age 16 but under age
26 and meet the criteria for registration in accordance with the Military Selective Service Act. If I
am under age 18, I understand that my information will be transmitted to Selective Service but I
will not be registered until I reach age 18.
SELECTIVE
SERVICE
CONSENT
