Fillable Printable Application for Driver License - Hawaii

Application for Driver License - Hawaii

NOTE: ALL DRIVE R L ICENSE RECORDS WILL BE VERIFIED THROUGH THE NATIONAL DRIVER REGISTER FOR ST OP PER

INFORMATION. ALL DENIED APPLICATIONS WILL REQUIRE WRITTEN CLEARANCE FROM JURISDICTION(S) THAT PLACED THE

STOPPER(S).

Advance health-care directive means an individual instruction, in writing, a living will, or a durable power of attorney for health-care

decisions.

Section 286-102.5, Hawaii Revised Statutes (HRS) requires all male applicants between the ages of 18 through 25 to be automatically

registered with the United States Selectiv e Service System. By submitting this application for the issuance of a permit, license, duplicate or

renewal, the qualied applicant is consenting to registration with the United States Selective Service System, if so required by Federal law.

I acknowledge that my SOCIAL SECURITY number I am providing is required by Sections 19-122-1, 19-122-3, 19-122-23 and 19-122-302.

Hawaii Administrativ e Rules, and Section 286-111, Hawaii Re vised Statutes, in accordance with Section 7 of the Privacy Act and 42 United

States Code, Section 405(c)2 (c). I further acknowledge m y SOCIAL SE C URITY number, or if I am unable to obtain a social security number

as evidenced by ofcial notication by the Social Security Administration to the county driver licensing ofce, a randomly generated alternate

driver license number shall be issued by this agency for the sole purpose of providing me with a driver’s license.

IMPLIED CONSENT LAW: I agree to submit to a chemical test or tests of my blood, breath or urine for the purpose of determining the alcohol

or drug content of my blood when testing is requested by a police ofcer acting in accordance with Section 291E-11, Hawaii Revised Statutes

(HRS). The license of anyone who refuses to be tested shall be subject to administrative revocation pursuant to Section 291E-41 , HRS. I

hereby certify, under penalty, that all the abov e information is true and correct, that I am the person named and described in this application.

APPLICANT’S SIGNATURE ________________________________________________________________ DATE ___________________________

NOTICE: Section 11-15 of the Hawaii Revised Statutes requires that a person registering to vote provide, under oath, his or her social security

number, if any. An application lacking this information, therefore, will be denied. Pursuant to Section 7 of the federal Privacy Act (P.L. 93-579 ),

be advised that this information ma y be released to gov ernment agencies for government purposes.

YES

MALE

FEMALE

NAME (Last, F irst, Middle)

MAILING ADDRESS (Street and Apt. or House No. , or P.O. Box, City, State and Zip Code)

HAWAII P RINCIPAL RESIDENCE ADDRESS (Street and Apt. or House No., City and State, Zip Code)

OCCUPATION BUSINESS ADDRESS

FT. IN.

WEIGHT

LBS.

COLOR

HAIR

COLOR

EYES

SEX

HEIGHT

1. Have you previously held a driver’s license in Hawaii,

another State or Country? ...................................................

If YES, _____________________________________

2. WITHIN THE LAST THREE (3) YEARS, have you:

A ) Ever been con victed in the State of Hawaii for driving

without a license? ...........................................................

If YES, _____________________________________

B ) Had an application for any driver license been refused ? ...

If YES, _____________________________________

C) Had any such license been suspended or revoked? .....

If YES, _____________________________________

Has such license been reinstated? ...............................

D) Ever been required to deposit proof of Financial

Responsibility under the Motor Vehicle Financial

Responsibility laws of the State of Hawaii ? ...................

(State or Country) (Lic. No. & Exp. Date)

(Date) (Reason)

(County) (Date)

(Date) (Reason)

3. ARE YOU WEAR ING CONTAC T LE NSE S? ..........................

4. The medical information in the following three questions will be

used only for the purpose of determining your eligibility to drive.

The answers to the questions will be kept condential

A ) Within the last two years, hav e you had a loss of

consciousness or ph ysical control, w hich affected your

functional ability to safely operate a motor vehicle? ......

B) Has your ability to drive been impaired (due to injury or

illness) within the last two years ? ...................................

C) If you marked “YES” to either of the above, which of the

following condition(s) was it related to?

(You must mark at least one box)

Neurologic/Orthopedic/Arthritic Conditions

Seiz u re /Aneurysm/Stroke/Blackout Spells

Drug Addiction Diabetes

Other: (Explain) ____________________________

______________________________________

Blood Pressure

Chronic Alcoholism

Heart/Lung Condition

YES

Page 1

SOCIAL SECURITY NUMBER

PLEASE CHECK ANSWER YES OR NO AND COMPLETE THE INFORMATION REQUESTED

DATE OF BIRTH

STATE OF HAWAII DRIVER LIC ENSE APP LICATION

CHECK TRANSACTION REQUESTED

LICENSE RENEW AL

INSTRUCTION PERMIT (New, Duplicate, Renewal)

DUPLICATE (Temporary, Lost, Name Change/Address)

OUT OF STATE TRANSFER

For Ofce Use Only

DRIVER LICENSE NUMBER/INSTRUCTION PERMIT NUMBER

TYPE RESTRICTION EYE TEST

LE RE

Do you wish to be an organ / tissue

YES

donor?

Do you wish to have a Veteran

YES

designation?

NOTE: Applicable to any person who served

in any of the uniformed services of the United

States and was discharged under conditions

other than dishonorable. Documentary evidence

required.

Do you have an advance health care

YES

directive?

Month

(MM)

Day

(DD)

Year

(YYYY)

AFFIDAVIT ON APPLICATION FOR V OTER REGISTRATION ( STATE OF HAWAII RESIDENTS ONLY !!)

For ofce use only

________________________

Afdavit Number

I.D. DL99 Loc. Code 98

Do you wish to register to vote? If “NO”, STOP! If “YE S”, continue on.

Are you a registered voter in another state?

If so , where? ________________________________________________________________________

Home Phone __________________________ Business Phone _______________________________

Address/County/State/Zip (your voter registration will be cancelled in that state )

For election information, call the State of Hawaii Voter Hotline at 1-800-442- VOTE (8683 )

The ofce at which a person registers to vote is condential. A person’s declination to register to vote is condential and is used for voter

registration purposes only (National Voter Registration Act of 1993). §11-15 Hawaii Revised Statutes requires that a person registering to vote

provide, under afrmation, a social security number. Any application lacking this information will be denied. Pursuant to Section 7 of the Pri-

vacy Act, be advised that this information may be released to government agencies for government purposes.

FOR FEDERAL, STATE AND COUNTY ELECTIONS (you must meet all of the following qualications to register to vote.)

I hereby swear or afrm that I am:

• A citizen of the United States : ( Non-U.S. Citizens including U.S. Nationals do not qualify) .............

• At least 16 years of age. .....................................................................................................................

How e ver, I understand that I must be 18 years old by election day to vote; and

• A resident of the State of Hawaii ........................................................................................................

The residence in this afdavit is not simply because of my presence in the state, but that the residence was acquired with the intent

to make Hawaii my legal residence with all of the accompanying obligations therein.

ALL INFORMATION ON THIS AFFID AVIT IS TRUE AND CORRE C T.

Signature ___________________________________________________ Date ________________

If you do not sign, we will assume you do not wish to register to vote.

YES

WARNING: Any person knowingly

furnishing false information may be

guilty of a Class C felony punish-

able by up to 5 years imprisonment

nd/or $10,000 ne.

Page 2

NOTICE: Section 11-15 of the Hawaii Revised Statutes requires that a person registering to vote provide, under oath, his or her social security

number, if any. An application lacking this information, therefore, will be denied. Pursuant to Section 7 of the federal Privacy Act (P.L. 93-579 ),

be advised that this information ma y be released to gov ernment agencies for government purposes.

MALE

FEMALE

NAME (Last, F irst, Middle)

MAILING ADDRESS (Street and Apt. or House No. , or P.O. Box, City, State and Zip Code)

HAWAII P RINCIPAL RESIDENCE ADDRESS (Street and Apt. or House No., City and State, Zip Code)

Sex

SOCIAL SECURITY NUMBER DATE OF BIRTH

Year

(YYYY)

Day

(DD)

Month

(MM)