Fillable Printable Diver License/ Identification Card Application - Arizona

Diver License/ Identification Card Application - Arizona

DRIVER LICENSE / IDENTIFICATION CARD APPLICATION

Type:  Driver License  Motorcycle  Instruction Permit  Identification Card

You are required by A.R.S. §§ 28-3158(D)(5) and §§ 28-3165(F), under authority of 42 U.S.C. §§

405(c)(2)(C) and

666 (a)(13)(A), to provide your Social Security Number. It will be used to verify your

identity and to comply with federal and state child support enforcement laws. It will not be used as your

driver license or identification card number.

Social Security Number

Applicant Name (first, middle, last, suffix)

−

Residence Street Address (Unit # / Apt #)

City

State

Zip

Mailing Address (if different from above) (Unit # / Apt #)

City

State

Zip

 Street  Mailing Which address do you want to appear on your license?

Sex

 Male  Female

Weight

Height

Eye Color

Hair

Date of Birth

Current Driver License Number

Name on Current Driver License or ID (if different from above)

Class

 Operator  Motorcycle  Commercial (CDL)  Identification Card

State

Issue Date

Expiration Date



Yes



No Has your driving privilege ever been suspended, disqualified, canceled, denied or revoked?

If Yes:

States

Dates

Reasons

 Yes  No Is your driving privilege now suspended, disqualified, canceled, denied or revoked?



Yes



No Do you have a license from more than one state or jurisdiction?

 My vehicle is registered in another state (indicate which state):

State



I am active duty military or family member.

 I am an out-of-state student or family member.

 I want to show a medical alert condition on my license/ID (must submit physician or registered nurse practitioner statement).



I also want this alert maintained on my permanent computer record. (If not checked, when you reapply or request a duplicate, the alert will not

appear on your license/ID unless you resubmit a physician or registered nurse practitioner statement.)

 I consent to the release of personal information contained in my driver license and vehicle record. I understand that this is not a one-time consent that

applies only to a specific individual or organization, but is instead a general consent that applies to all requests from any and all individuals or

organizations for any purpose, until revoked by me in writing. Consent for a vehicle record applies to all owners.

 Yes  No Do you have a physical, psychological or visual condition (other than wearing glasses or contact lenses) or alcohol/drug dependency or are

you taking any medications that could affect your ability to safely operate a motor vehicle? (driver license applicants only)

Please Explain

 Yes  No Have you ever been determined to be incapacitated by a court? (driver license applicants only)

 Yes  No Are you a United States citizen who wishes to register to vote or update your existing voter registration?

 I want to be placed on the permanent early voting list and receive an early ballot by mail for each election I am eligible.

Party Preference

 DONOR♥ I check this box to become an organ/tissue donor and join the DonateLifeAZ Registry. DONOR♥ will print on my license.

 I am a U.S. Military veteran and would like the word “VETERAN” printed on my license/ID. (Documentation Required)

All Applicants: I certify that the information above is true and correct. I understand that I must report a change of address or name to MVD within 10

days. All Driver Applicants: I understand the laws, rules and regulations described in the Arizona Driver License Manual, and that I must report to

MVD in writing, within 10 days, any medical condition that develops or worsens that may affect my ability to safely operate a motor vehicle.

Male Applicants Under 26: By submitting this application, I consent to registration with the Selective Service System if I am required to register

under federal law. If I am under 18, I understand that I will be registered as required by federal law when I become 18.

Voter Registration: I certify that I am not a convicted felon or my civil rights have been restored, and that I have not been adjudicated incompetent. I

certify that I am a United States citizen. Submitting a false voter registration is a Class 6 felony. Your decision to register to vote or not, and where

you submitted your application, will remain confidential.

Applicant Signature (If under 18, Legal Guardian Certificate on the back must be completed.)

Acknowledged before me

this date.

Notary or MVD Agent Signature

Date

County

State

Commission Expires

40-5122 R10/14 azdot.gov

Clear

Relationship To Applicant (check one) – #1 & 2 require only one signature; #3 may require one or more, depending on the proof provided; #4 requires both.

 1. Natural/Adoptive parent, married to other natural/adoptive parent  4. Natural/Adoptive parent not married to other natural/adoptive parent,

 2. Natural/Adoptive parent with sole custody share joint custody

 5. Other: __________________________________________________

 3. Full legal guardian (proof required)

_________________________________________________________________________________

This certificate is for a driver license or permit application. I am responsible for any negligence or willful misconduct caused by the minor applicant.

Name (first, middle, last, suffix)

Name

Signature

Acknowledged

before me this date.

Notary or MVD Agent Signature

Acknowledged

before me this date.

Notary or MVD Agent Signature

Date

County

State

Commission Expires

Date

County

State

Commission Expires

The applicant completed at least 30 hours of supervised driving practice, including at least 10 hours at night for a graduated driver license; at least

30 hours of motorcycle riding practice for a motorcycle license or motorcycle endorsement.

Parent or Guardian Name (first, middle, last, suffix)

Parent or Guardian Name

Parent or Guardian Signature

Acknowledged

before me this date.

Notary or MVD Agent Signature

Acknowledged

before me this date.

Notary or MVD Agent Signature

Date

County

State

Commission Expires

Date

County

State

Commission Expires

MVD USE

Medical Observations

Medical Certificate Expires

MVD Agent

Birth Certificate State/Control #

Tribal CIB #

Citizenship/Immigration Type/Form #

Social Security #

State

Driver License/ID Card #

Issue Date

Exp. Date

Credit Card

Issuing Institution

Exp. Date

Additional Documents

MVD Agent

Visual Acuity

Visual Field

Right

20/  Blind

Left

20/  Blind

Both

20/

Right

Nasal-Right

Left

Nasal-Left

 Corrective Lens

MVD Agent

Rules of the Road Road/Skills Test Motorcycle Knowledge

1st

Date

Series

Grade

MVD Agent

Date

Grade

MVD Agent

Date

Grade

MVD Agent

2nd

Date

Series

Grade

MVD Agent

Date

Grade

MVD Agent

Date

Grade

MVD Agent

3rd

Date

Series

Grade

MVD Agent

Date

Grade

MVD Agent

Date

Grade

MVD Agent

1st 2nd 3rd Points Actual Driving Test Automatic Failure Codes

10 ea Fails to make full stop

Offset Backing Other (describe below)

10 ea Crowding center line A – Struck pylon E – Involved in accident

10 ea Following distance B – Distance from curb F – Dangerous action

10 ea Right of way to vehicle or pedestrian C – Jumped curb or took too long G – Serious violation

10 ea Over speed limit (within 5-10 mph) D – Inability after three attempts H – Refused instructions

4 ea Choice of proper lane

Immediate Rejection: I – Failed vehicle inspection

4 ea Signaling

Comments

4 ea Use of brakes

4 ea Observation and planning

2 ea Operation of motor vehicle

2 ea Position after stopping

2 ea Waits too long

Validation

2 ea Too slow

2 ea Steering

2 ea Improper turn

Total Points Off

Legal Guardian

Certificate

Driving Practice

Certificate