Fillable Printable Application for License/Permit - Vermont

Application for License/Permit - Vermont

Application for License/Permit

DEPARTMENT OF MOTOR VEHICLES

Agency of Transportation

802.828.2000

dmv.vermont.gov

Complete both pages or form will be returned

I am Applying for a

(Check all that apply)



Driver’s

License (OPR)



Junior Driver’s

License (JUN)



Learner Permit (LRN)



Real ID Compliant



Original Issue



Transfer from Out of State



Privilege Card (Non-Real ID)



Renewal



Add Endorsement(s):



Enhanced (EDL)



Address Change



Other:

Vermont Identification Information - Do you now have, or did you ever have a Vermont:

Driver license?



Yes



Learner permit?



Yes



Non-driver ID Card?



Yes



If “Yes”, enter the identification number

as it appears on the license, learner

permit, or non-driver ID card

VERMONT LICENSE, PERMIT, or NON DRIVER ID CARD NUMBER

LAST NAME

Do you have a driver license that is valid or that expired within the

past year, issued by another US State, the District of Columbia or a

Canadian Province? 

Yes



FIRST NAME

If “Yes”, where was it issued? ________________________________

MIDDLE NAME

Date of Expiration: License Type: License Number:

ADDRESS WHERE YOU GET YOUR MAIL

(mailing address)

- Include Street Number and Name (If PO or Private Box, also fill in “Address Where You Live” below)

City or Town State Zip Code

ADDRESS WHERE YOU LIVE

(physical address)

– This address will be printed on your license

City or Town State Zip Code

Social Security Number: Date of Birth (MM/DD/YYYY): Place of Birth (City, State & Country):

The disclosure of your social security or federal identification number is mandatory, is solicited by the authority granted by 42 U.S.C. § §405(c)(2)(C) and/or 666(a)(13) and

will be used by the Department of Motor Vehicles in the administration of motor vehicle, tax and child support laws, to identify individuals affected by such laws.

Gender:



Male



Female

Eye Color: Height: Weight:

Name, Address or Other Changes

If address change required for voter registration, complete voter registration on last page.

Has your name changed?



Yes



Has your mailing address changed?



Yes



Has the physical address changed?



Yes



Other Change(s):



Yes



If applicable, list all former names exactly as they appeared on your previous licenses.

DMV USE ONLY

Audit Line:

PID __________________

 Print (270)

 Name CHG

(231)

 DOB CHG (231)

 MISC CHG

(231)

POB SEX EYE HT WGT

 Mail Address

(232)

 SS# CHG (232)

 Physical ADD (233)

ADD CHG DEL

 Voter Reg

 Create

 220  260

 222  225

 228  227

 234



DOC LOC

 NNL Photo

 VISA

USCIS Doc______

 Eye Exam

Endorsements:

___ ___ ___



QSD



PDPS



QCS

OPR NEW 16

OPR RENEW 17

OOS LIC #

JUNIOR OPR 18

PERMIT NEW 19

Restrictions:

___ ___ ___

City & State (OOS)

PERMIT RENEW 20

EDL ($25.00) 33

Issue Date (VT)

EXAM, FIRST 21

EXAM, SUBSEQ 22

(Examiner – Authorized Agent)

RATER # DATE By:

Expire Date (VT)

TOTAL $

TA-VL-21 30M 06/2015 MTC Complete both pages or form will be returned! Page 1 of 2

V T

Questions/Certifications

1 Do you need glasses or contact lenses when driving?

 Yes  No

2 Is your Driver’s License suspended, revoked or cancelled in this or any other State or jurisdiction?

 Yes  No

3 Do you have a Driver’s License from more than one State or jurisdiction?

 Yes  No

Do you have a history of a physical or mental condition including diabetes, epilepsy, seizures or blackouts (other than properly

corrected eyesight) that could affect your ability to safely operate a motor vehicle? If ‘Yes’ indicate condition(s)/medication(s):

 Yes  No

5 Do you wish to be registered as an organ & tissue donor?

 Yes  No

6 a)

Are you a U.S. Citizen Or,

 Yes  No

If 6a is no, Do you have proof of legal presence?

 Yes  No

Are you a veteran of the US Military & want “VETERAN” printed on your License? (form #TA-VL-24 must also be included)  Yes  No

Does your current license contain a school bus endorsement and you wish to keep it? If ‘Yes’

 Type I or  Type II

 Yes  No

Does your current license contain a motorcycle endorsement and you wish to keep it?

 Yes  No

Voter Registration Questions

NOTE: If you do not check either box, you will be considered to have decided not to register to vote.

I am a U.S. Citizen AND I would like to apply to register to vote OR I am changing my address and I would like the Secretary of State to be

notified?



Yes



No - I Decline to Register/Already Registered/I do not want to notify the Secretary of State

The last address at which I was registered to vote if any, was (Do Not Complete Unless Currently Registered to Vote at a Previous Address):

Street Address City/Town County State

VOTER’S OATH (Vermont Constitution, Chapter II, Section 42)

Every voter must take the voter’s oath below before voting for the first time in Vermont. You can attest for

yourself that you have taken the oath or you can have any person over 18 attest that you have taken the oath below: You solemnly swear (or affirm) that whenever you give your

vote or suffrage, touching any matter that concerns the State of Vermont, you will do it so as in your conscience you shall judge will most conduce to the best good of the same,

as established by the Constitution without fear or favor of any person.



Yes

- I certify that I took the Voter’s Oath myself OR the voter's oath was administered to me by a person over eighteen.

I hereby affirm, under penalty of perjury, that the information on this form is true to the best of my knowledge. If taking the driving test, I

certify the vehicle in which I take my driving test is representative of the vehicle class and type that I intend to operate. This declaration

made under penalties of 23 VSA § 202 & § 4110. Submission of a false voter registration application is subject to the penalties of perjury

as provided in 17 V.S.A. § 2011 and in 42 U.S.C. § 1973 gg – 10.

Signature of Applicant:

Date:

Signature of Parent or Guardian (if applicant is under 18). I hereby consent to the issuance of the license/permit:

 Parent



Guardian

Date:

Phone Number: Email Address:

OFFICE LOCATIONS

Bennington 120 Depot Street South Burlington 4 Market Street

Dummerston 870 US Route 5 (AOT District #2 Office) St. Albans 27 Fisher Pond Road

Middlebury 7 Mahady Drive (Court House) Springfield 100 Mineral Street, Suite 103

Montpelier 120 State Street St. Johnsbury 1998 Memorial Drive

Newport 100 Main Street, Suite 130 White River Junction 36 S Main St (American Legion)

Rutland 101 State Place

Hours vary by location, visit dmv.vermont.gov or call 888-99-VERMONT (888-998-3766) for hours

Learner Permit $17.00 Exam Road/Driving $18.00

JR Operator License $30.00 Exam Written $30.00

Operator License $48.00 (4 year) or $30.00 (2 year) Out of State Transfer $18.00 (additional)

Enhanced Driver License $25.00 (additional) Motorcycle Endorsement $2.00 per year (additional)

AVAILABLE LICENSE TYPES:

•

REAL ID: Required for flying on commercial aircraft or for access to certain federally controlled facilities (federal courts, federal buildings,

nuclear power plants).

•

PRIVILEGE CARD: Will be marked “Not for Federal Identification” to indicate card is not Real ID compliant.

•

ENHANCED (EDL): An EDL is Real ID compliant. U.S. citizens returning home from Canada, Mexico, the Caribbean or Bermuda, by land or

sea, are required to present a U.S. Passport or an Enhanced License/ID. Must be Vermont resident AND U.S. Citizen. Must also complete VL-11.

NOTES: All original issue (first time) licenses must be applied for in person at a DMV office. Application must bear the personal signature of the applicant and signature must

be in ink. If the applicant is a minor, (under age 18) the written consent of the applicant's parent, guardian, or other person standing in loco parentis will be required. In the case of

"in loco parentis", that individual must submit a written authorization from a parent for the issuance of the card.

DOCUMENTS REQUIRED

Regardless of whether you are a new applicant or current card holder, you must bring the same types of documents. New applicants and current Driver’s

License and ID card holders must present the required documents from each of these four categories.

Identity and date of birth

Must provide one of the following:



Valid, unexpired U.S. passport, certified copy of a birth certificate filed with the State Office of Vital Statistics or equivalent agency in the

individual’s state of birth



Consular Report of Birth Abroad (CRBA) issued by the U.S. Department of State (Form FS-240, DS-1350 or FS-545)



Valid, unexpired Permanent Resident Card (Form I-551)



Certificate of Naturalization issued by DHS (Form N-550 or Form N-570)



Certificate of Citizenship (Form N-560 or Form N-561) issued by DHS



Driver’s license/identification card issued in compliance with the standards established by Real ID (cannot be expired more than one year).

Lawful status in the United States (If undocumented see http://bit.ly/UndocumentedVT for ID requirements)

The documents required for proof of identity and date of birth will also establish lawful status in the United States in most cases, provided the Vermont

DMV is able to authenticate and verify the documents under existing and available verification systems. Foreign nationals must provide a passport and

visa, alien registration receipt card (green card), or other proof of legal presence for inspection and copying.

Social Security number.

Present your Social Security card. If your Social Security card is not available one of the following forms may be used in its place: W-2 form, SSA-1099

form, pay stub showing name and SSN (minimum of last 4) or a letter from the Social Security Administration indicating ineligibility to receive a Social

Security number.

Vermont residency and current residential address.

You must present two documents that include your name and current Vermont residential address that demonstrate residency in the state of Vermont.

Examples: piece of mail with current name and Vermont street address including city/town (no P.O. Boxes), utility bill (must list service address),

property tax bill with physical location, lease or landlord statement, Homeowners/renters insurance (policy/proof of claim), Vermont EBT or Vermont

AIM identification card.

NOTE: Your name must verify with Social Security Administration (SSA). If there have been multiple changes to your name, you must provide

documentation to prove the continuity of the names. For example: Marriage or civil union certificate (certified copy issued by town/city), Marriage or

civil union dissolution or Probate court name change document.

VETERAN’S INDICATOR ON VERMONT LICENSE/ID

All Vermont residents who are veterans of the U.S. Armed Forces and were honorably discharged or discharged under honorable conditions can choose to have

a Veteran’s Indicator on their Driver’s License, Learner’s Permit or Non-Driver ID card. If they choose this, the word “Veteran” will be printed on their

license, permit or ID card. There is no additional fee for the Veteran’s Indicator, but all regular transaction fees will apply. Form # TA-VL-24 (Application

for Veteran Designator) must be completed to show proof of veteran status and submitted with the license, permit or non-driver ID application.

APPLICATION FOR ADDITION TO CHECKLIST – VERMONT VOTER REGISTRATION APPLICATION

You are eligible to vote in the town or city where you physically reside if as of Election Day, you: are a United States citizen / are a resident of Vermont / are

18 years old / take Voter’s Oath. Residency for voting purposes is defined as “a person who is domiciled in the town as evidenced by intent to maintain a

principal dwelling place in the town indefinitely and to return there if temporarily absent, coupled with an act or acts consistent with that intent.”

You only need to take the Voter’s Oath ONCE. If you were previously registered to vote in Vermont you have already taken the Voter’s Oath. You can attest

that you have taken the voter's oath for yourself or a DMV employee can administer the Voter’s Oath to you.

You are not automatically registered to vote by completing this application—your Town or City Clerk will review your application to be sure that you meet all

eligibility requirements. The Clerk will notify you in writing if your application is approved and notify you of the location of your polling place. If your

application is denied, the Clerk will notify you explaining why you are not eligible and also explain how you can file an appeal to the Board of Civil Authority

in your Town or City.

The laws relating to voter registration are in 17 V.S.A. §§ 2121 to 2150 (Chapter 43). If you have questions, you may call the Office of the Secretary of State at

802.828.2363 or toll free in Vermont at 800.439.8683 or visit online at sec.state.vt.us/elections/voters.