Fillable Printable Application Form for a Driving Licence D401

Application Form for a Driving Licence D401

1. Have you previously held a learner permit and/or driving licence in Ireland?* Yes

If yes, which one? Learner Permit

Driving Licence

Driver number* (if known)

(You will ﬁ nd this on Field 5 of the paper licence or Field 4d on a plastic card licence.)

2. Title Mr Mrs Miss Ms

Other

(please specify)

Name to appear on the licence

3. First name(s)*

4. Surname *

As it appears on your birth certiﬁ cate

5. First name

6. If your surname has changed since your last licence issued please indicate the reason

Marriage

Deed Poll

Use of Irish name Divorce/Separation

Previous names

7. Address 1*

Address 2

Town*

County/City*

Postcode

8. Date of birth*

If aged 70 or over, a valid medical report will be required.

Day Month Year

9. Gender* Male Female

10. PPSN* Original proof of PPSN must also be provided. See page 4 of the Guidance Notes.

If born in Republic of Ireland, please state County. If born abroad, please state country

11. Place of birth*

12. Mobile no.

Landline

Email address

Part 1: Personal Details (See Part 1 of accompanying guidance notes) *Mandatory ﬁ eld

Application form for

a Driving Licence D401

Please read accompanying guidance notes before

completing this form. Please complete this form in

block capitals using a black ballpoint pen. Please place

an X in the appropriate boxes e.g.

Please do not

photocopy this form as it may reduce its quality and

result in your application being delayed or rejected.

July 2014

13. Preferred method of communication* Email Post

(other channels of communication may be used in certain circumstances)

Part 2: Licence Details (See Part 2 of accompanying guidance notes) *Mandatory ﬁeld

14. Application type*: First time

Renewal

Exchange

Replacement

If replacement, please specify the reason:

Add/remove categories

Personal detail change

Lost/stolen

Damaged

Not received

Other

(please specify)

15. On receipt or exchange of this driving licence, will you hold a driving licence issued by

another country?* Yes

If ‘Yes’, please provide details below:

Issuing country

Driving licence no.

16. If your licence was lost or stolen or damaged please sign the declaration below and get the declaration witnessed

and stamped at your local Garda Station.

I declare my licence lost/stolen/damaged

(circle as appropriate)

Signature of Applicant

I certify that the applicant has declared his/her licence lost/stolen/damaged.

Name of Garda

Signature of Garda

Office uSe OnLy

17. Licence category required:

D1E

C1E

Part 3: exchanging a Licence (See Part 3 of accompanying guidance notes)

18. Has the licence you are exchanging for an Irish licence been obtained on foot of an exchange

of another licence from another country? Yes

If ‘Yes’, please state the country where the original licence was obtained:

19. I took up normal residence in Ireland on

Day Month Year

Part 4: Organ Donation (See Part 4 of accompanying guidance notes)

2o. Place an X in the box provided if you would like code 115 to appear on your licence indicating your wish

to become an organ donor.

July 2014

Part 5: Driver fitness (See Part 5 of accompanying guidance notes) *Mandatory ﬁeld

Part 6: Declaration by Applicant (See Part 6 of accompanying guidance notes) *Mandatory ﬁeld

44. i hereby declare that:

Ireland is my normal place of residence. I am not currently disqualiﬁed from holding a learner permit or driving licence.

The address given is my normal residence. The accompanying supporting documents relate to me. The information

I have given in this application is correct.

THiS DecLARATiOn MuST Be SiGneD By THe PeRSOn TO WHOM THe Licence iS TO Be iSSueD

Applicant’s signature*

Day Month Year

Information contained in this form may be subject to disclosure under Section 60 of the Finance Act, 1993 (No. 13 of 1993) as amended by Section 86

of the Finance Act, 1994 (No. 13 of 1994) and regulations made thereunder. List of disclosees is registered with the Data Protection Commissioner.

An electronic version of all information contained in this application may be retained for a period of at least 20 years.

21. Do you need to wear glasses

or lenses for driving?* Yes

(If yes Code 01 will be added to your licence)

If in the past you answered ‘Yes’ to this question

and are now answering ‘No’ you must provide a

current eyesight report with your application.

Health and fitness

Have you ever had, or do you currently suffer from,

any of the following conditions?

22. Diabetes treated by insulin and/or sulphonylurea

tablets. Ask your doctor whether you are on these or

not. No need to tell us if managed

by other tablets and/or diet. Yes

23. Epilepsy Yes No

24. Stroke or TIAs

with any associated

symptoms lasting longer

than one month Yes

25. Fits or blackouts Yes No

26. Any type of brain surgery, brain abscess or severe head

injury involving in-patient treatment

or brain tumour or spinal injury

or spinal tumour Yes

27. An implanted cardiac pacemaker Yes No

28. An implanted cardiac

deﬁbrillator (ICD)

Yes No

29. Repeated attacks of sudden

disabling dizziness Yes

30. Any other chronic neurological condition such

as multiple sclerosis, motor neurone disease,

Parkinson’s disease and

Huntington’s disease Yes

31. Persistent alcohol misuse

or dependency Yes

32. Persistent drug misuse

or dependency Yes

33. Serious psychiatric illness or mental

health problems Yes

34. Parkinson’s disease Yes No

35. Sleep Apnoea syndrome Yes No

36. Narcolepsy Yes No

37. Any condition affecting your

peripheral vision Yes

38. Total loss of sight in one eye Yes No

39. Any condition affecting both eyes, or the remaining eye if

you only have one eye (not including

colour blindness or short

or long sight) Yes

40. A serious hearing deﬁciency which

has worsened since your last

application/renewal Yes

41. Any persisting problem with arm(s) or leg(s) which needs

driving to be restricted to certain

types of vehicle or those with

adapted controls

Yes No

42. Severe learning disability

Yes No

43. (a) Is your vehicle adapted because

of a physical disability to enable

you to drive? Yes

(b) Has there been any deterioration in the disability

since you last applied for a driving

licence or a learner permit? Yes

A transient ischemic attack (TIA) is an event with stroke symptoms that lasts less than 24 hours before disappearing (sometimes called a mini-stroke).

While TIAs generally do not cause permanent brain damage,they are a serious warning sign of stroke.

An Implantable Cardioverter Deﬁbrillator (ICD) is an electronic device which monitors your heart continuously. The ICD is programmed to detect abnormally fast or

slow heart rhythms.

which has worsened since your last application/renewal.

If in doubt, please consult your family doctor.

(Please keep signature within the box)

if you answer ‘yes’ to any of the questions below 22 to 42 or 43(b), you will also be required to submit a medical report dated within one month of application date.

July 2014

How to apply

You must apply in person at any one of the new NDLS centres

nationwide. Before attending the centre, please read the

list of supporting documents required to complete your

application. This list can be found on the accompanying

guidance notes and at NDLS.ie. You will not need to provide

photographs as your photograph will be taken in the centre.

You will also be asked to provide your signature digitally at

the time of photograph capture. These will then appear on

your licence. The centres are open from 9am to 5pm each day

Monday to Friday inclusive, and remain open through lunch

times. They are also open from 9am to 2pm on Saturdays.

Part time centres in Belmullet and Clifden are open from

9am to 4pm one day per week. Any future change of opening

hours will be communicated on www.ndls.ie

Book an Appointment

If you wish to book an appointment to apply for your licence

you can do so at www.ndls.ie. This service is available online

only. You need to have your driver number or PPSN to use the

service.

identity validation

You will need to bring certain documents with you in order

to conﬁrm you are the person that is applying for the licence.

This is an important requirement as it will increase the

security of your licence and reduce the risk of fraud. This

is not intended to inconvenience customers but rather to

improve the service for all drivers and to comply with EU

Directives and best international practice. All customers

must be ‘normally resident’ in Ireland and will be required to

provide documents in support of their application to conﬁrm

their residency entitlement, identity, address and PPSN.

A full list of the types of documents that can be used in

each category is available on page 4 of the accompanying

guidance notes and on www.ndls.ie. We would strongly

advise you to review this list before visiting an NDLS centre as

not having the right documents with you will prevent your

application from being processed on the day in the nDLS

centre. Any documents you bring with you must be originals

– photocopies will not be accepted. Identity documents may

be retained by the NDLS to enable the processing of the

application. These documents will be returned to you after

your application has been processed.

Remember that the documents required to conﬁrm your

identity are in addition to any other documents that might be

required as part of your application, for example, an eyesight

report or medical report, a Certiﬁcate of Competency (driving

test pass certiﬁcate) or a Theory Test Certiﬁcate. If you hold

an existing licence, this must be surrendered to NDLS as part

of your application package.

Locations

The locations of all of the NDLS centres are included on page 4

of the accompanying guidance notes and are also available on

www.ndls.ie

further information

For further information please refer to the accompanying

guidance notes and ndls.ie For further support you may email

inf[email protected]

fees and payment

The fees for the driving licence are set out below:

Type of Licence cost

Ten year licence (or period greater than three years) €55

Three year licence (issued on age and medical grounds) €35

One year licence (issued on medical grounds) €25

Adding a new licence category to an existing car licence €35

To exchange a foreign licence €55

To replace a licence exchanged abroad €35

Change of personal details No fee

Licence for over 70s No fee

The National Driver Licence Service will accept the following

payment methods with your application:

• Cash (where you attend in person at the

NDLS centre)

• Cheque

• Bank draft

• Money order

• Debit card / credit card / prepaid credit card

The NDLS will only accept one method of payment for each

application. The NDLS will only accept one payment for one

application – a single payment for multiple applications will

not be accepted.

Cheque, bank drafts or money orders must be made payable

to ‘National Driver Licence Service (NDLS)’. For applications

paid for by cheque, please note that those applications will be

placed on hold until the cheque clears.

The NDLS will process debit and credit card payments in

accordance with the Payment Card Industry (PCI) rules. If you

wish to use a third party debit or credit card for payment,

then the third party must be present in person to make the

payment.

Checklist for your Driving

Licence application

The majority of driving licence applications will fall in to one of the six examples

below. In all cases please submit a fully completed NDLS ‘Application Form for a

Driving Licence’ and the correct fee. For more information please see the Guidance

Notes in the ‘Forms’ section on www.ndls.ie

THe nDLS cenTReS ARe OPen MOnDAy TO fRiDAy 9.00AM – 5.00PM

(incLuDinG LuncHTiMe) AnD SATuRDAy fROM 9.00AM – 2.00PM.

ViSiT WWW.nDLS.ie fOR THe ADDReSS Of yOuR neAReST cenTRe

OR DOWnLOAD OuR nDLS cenTRe APP:

i have just passed my driving test and am applying

for my ﬁ rst driving licence so i must submit:

• A Certiﬁ cate of Competency (dated within 2 years)

• My current/most recent Learner Permit

• Evidence of PPSN*

• A completed NDLS Medical Report Form

if required in my case

• If the address on my application form is different

to that on my current Learner Permit I will

need to provide evidence of address*

My licence was lost/stolen and i am applying for

a replacement so i must submit:

• A completed Lost Licence Declaration

(see question 15 of the Application Form)

• Photographic I.D.*

• Evidence of PPSN*

• A completed NDLS Medical Report Form if there

has been a change in medical ﬁ tness since last

licence issued

• If the address on my application form is different

to that on my lost/stolen licence I will need

to provide evidence of address*

i want to add a category to my licence so

i must submit:

• My current/most recent full licence

• My current Learner Permit

• A Certiﬁ cate of Competency (dated within 2 years)

• Evidence of PPSN*

• A completed NDLS Medical Report Form

if required in my case

• CPC (Certﬁ cate of Professional Competence)

if required in my case

• IBT (Intial Basic Training) if required in my case

• If the address on my application form is different

to that on my current licence I will need to

provide evidence of address*

i am renewing my licence so i must submit:

• My current/most recent full licence

• Evidence of PPSN*

• A completed NDLS Medical Report Form

if required in my case

• If the address on my application form is different

to that on my current licence I will need to

provide evidence of address*

i am exchanging my licence from another eu

or recognised country so i must submit:

• My current full licence

• Evidence of PPSN*

• Evidence of address*

• Photographic I.D.*

• A completed NDLS Medical Report Form

if required in my case

• A completed NDLS Eyesight Report Form

if exchanging a non EU licence

• Evidence of residency entitlement*

• If the address on my application form is different

to that on my current licence I will need to

provide evidence of address*

• Letter of Entitlement if required in my case

i am renewing my licence and changing my name

so i must submit:

• My current/most recent full licence

• Evidence of PPSN*

• Evidence of address* if address is changing

• Evidence of name change e.g. Marriage/Civil

Partnership Certiﬁ cate, evidence of divorce/

separation, evidence of deed poll enrolled in

the High Court. Please refer to website for further

information

*For a list of accepted proof of evidence, please see Lists 1-4

on the reverse.

nDLS centres

carlow Unit 7, First Floor, Graigue Village Centre, Graiguecullen, Carlow

cavan Unit 5, Cavan Shopping Centre, Main Street, Cavan

clare Unit 4, Ennis Shopping Centre, Ennis

cork Commercial Unit 1, Copley Hall, Cotter’s Street, off Copley Street, Cork

cork First Floor, Cork Co-operative Marts, Marsh Road, Skibbereen

cork Second Floor, 17 Market Square, Mallow

Donegal Unit 7, O’Boyce’s Corner, Port Road, Letterkenny

Donegal Eurohouse, Killybegs Road, Donegal Town

Dublin Unit 9, Leopardstown Shopping Centre, Ballyogan Road, Dublin 18

Dublin Unit H Own Door Ofﬁces, Citywest Shopping Centre, Citywest

Dublin Unit 236, Omni Park Shopping Centre, Swords Road, Santry

Dublin Unit 3, Floor 3, Clarehall Shopping Centre, Malahide Road

Galway Galway 2nd Floor, Block 1, Cityeast Business Park, Ballybrit Business Park

Galway Clifden (part-time), Station House Hotel

Kerry Mezzanine Unit, Manor West Shopping Centre, Tralee

Kildare 5B Elm House, Millennium Park, Naas

Kilkenny Unit 2E, First Floor, Cillin Hill Centre, Dublin Road, Kilkenny

Laois unit 29A, Laois Shopping Centre, Portlaoise

Leitrim Unit 7, Bridge Lane, Carrick-on-Shannon

Limerick Unit 29, Parkway Shopping Centre, Dublin Road, Limerick

Longford Suite 3, Business Centre, Longford Shopping Centre, Longford

Louth Ground Floor Unit 3, Southgate Shopping Centre, Dublin Road, Drogheda

Mayo New Antrim Street, Castlebar

Mayo Belmullet (part-time), Broadhaven Bay Hotel

Meath Unit 3 Finnegans Way, Emmet Street, Trim

Monaghan Ofﬁce 2, First Floor, Teach O’Cleircin, Old Cross Square, Monaghan

Offaly Room 201, Down Suite, Castle Buildings, Tara Street, Tullamore

Roscommon Unit 1, Racecourse Business Park, Roscommon

Sligo Ground Floor Millennium House, Stephen Street, Sligo

Tipperary Suite 5A, Second Floor, Powerstown House, Clonmel

Tipperary 10 Silver Street, Nenagh

Waterford Waterford Shopping Centre, Lisduggan, Waterford

Westmeath Golden Island Shopping Centre, Athlone

Westmeath Unit 1A, Mullingar Shopping Centre, Ashe Road, Mullingar

Wexford 7a The Square, Redmond Square, Wexford

Wicklow Unit C16, Wicklow Enterprise Centre, The Murrough, Wicklow

NB: In some instances the same document could satisfy more than one requirement. e.g. an Irish/EU passport

is adequate as photo ID and evidence of normal residency; a letter to you from Revenue showing your PPSN could

be used as both evidence of your address and evidence of your PPSN.

When applying, avoid queues by visiting the online booking system at NDLS.ie. Drivers with either a valid driver number

or PPS number can book their visit for a date and time that suits.

For further information visit NDLS.ie

List 3: Photographic i.D.

• Irish Passport (current or expired by no more than

12 months on the day of application)

• Irish Driving Licence or Learner Permit

• Current Passport for all non-Irish citizens

• Current National Identity Card for

EU/EEA/Swiss Citizens

• Irish Certiﬁcate of Naturalisation

• Current UK photo driving licence

• Current Public Services Card

• Current Irish Travel Document

List 2: evidence of address

(Evidence of document can be no more than 6 months

old at date of application and must exactly match

address on application form)

• Utility Bill (i.e. from your electricity/phone/

gas/cable television/broadband provider).

Printed online utility bills are accepted.

Mobile phone bills are not accepted

• Correspondence from an insurance company

regarding an active insurance policy - health/life/

house/car insurance

• Statement from Bank/Building Society/

Credit Union (Statements from Store cards/

catalogue companies are not accepted)

• Letter from Department of Social Protection/

Revenue

• Other ofﬁcial correspondence from an Irish

state agency

List 4: evidence of residency entitlement

• Irish/UK Long-form Birth/Adoption Certiﬁcate

• Certiﬁcate of entry in the Irish Register

of Foreign Births

• Irish Passport (current or expired by no more than

12 months on the day of application)

• Current Passport for all EU/EEA/Swiss Citizens

• Current National Identity Card for

EU/EEA/Swiss Citizens

• Irish Certiﬁcate of Naturalisation

• Current Certiﬁcate of Registration

(GNIB card) for non-EU/EEA/Swiss Citizens

(must be presented with current passport)

List 1: evidence of PPSn

• Public Services Card/Social Services Card

• Correspondence from Revenue/Department

of Social Protection showing PPSN

• P21/Tax Assessment/ Notice of Tax credits

• Receipt of Social Welfare Payment

• Medical Card / Drug Payment Scheme (DPS) Card

• Payslip or P60/P45

• European Health Insurance Card

• C2 card issued to self-employed contractors