Fillable Printable Driver's License or Identification Card Application - Nevada

Driver's License or Identification Card Application - Nevada

APPLICATION FOR DRIVING PRIVILEGES OR ID C AR D



ORIGINAL



RENEWAL



DUPLICATE



INSTRUCTION PERMIT

Information in boxes MUST be completed prior to visiting a DMV representative. Please PRINT in black or blue ink only.

LICENSE OR PERMIT

 Real ID  Standard



Driver Authorization Card

CLASSIFICATION

 Class C  Class A



Class M



Class B

ENDORSEMENTS

 J  G



IDENTIFICATION CARD

 Rea l ID  Standard



Seasonal Resident

CHANGE TO INFORMATION ON CARD:  NAME  ADDRESS  DATE OF BI R TH  SOCIAL SE CURIT Y NUMBER  SEX

LAST NAME (PRINT)

FIRST NAME

MIDDLE NAME

SUFFIX

NEVADA DL/DAC/ID NUMBER

SOCIAL SECURITY NUMBER

(not required for DAC)

DATE OF BIRTH

FUL L LEGAL NAME ON BIRTH CERTIFICATE

BIRTHPLACE

(CITY & ST ATE OR CO UNTRY)

 DO NOT SCA N MY BIRT H CERTIF ICATE

SEX (CIRCLE)

M F

HEIGHT

FT. IN.

WEIGHT

LBS.

HAIR COLOR

EYE COLOR

MOTHER’S MAIDEN NAME

PRIMARY PHYSICAL ADDRESS

MAILING ADDR ESS (IF DIFFERENT FROM PHYSICAL ADDRESS)

CITY, STATE, ZIP CODE

DAYTIME PHONE NUMBER

( )

EMAIL ADDRESS

ALL APPLICANTS MUST COMPLETE THIS SECTION

VOTER

REGISTRATION

OR ADDRESS

CHANGE

Would you like t o register to vote or make changes to your curr ent voter registration?  YES  NO

If you are a U.S. c itizen and already regis tered t o vote in Nevada, t his for m w il l update your voter regi stration address

 I do or  I do not want m y address updated f or voter registration purposes.

Did you move to a different county?  Yes  No If yes, you must submit a NEW voter registration application.

VOTER REGISTRATION APPLICATION N UMBER:

VETERAN

I declare myself an honorably discharged U.S. Armed Forces veteran and authorize the DMV to send  YES  NO

my personal information to the Department of Veterans Services to provide benefits information to me.

I have a U.S. Armed Forces honorable discharge and wish to have a veteran designation placed/retained 

YES



on my license. If y our card does not already have a veteran designation, pr esent proof of honorabl e discharge.

SELECTIVE

SERVICE

If you are a male at least 18 years of age and less than 26 years old, w ould you l ike to register wit h the

 YES  NO

Selecti ve S ervice? By regi stering, you will remain eligible for federal student loans, grants, benefit s

relating to job tr aining, most federal jobs and, if appl icabl e, citizens hip in t he U nited St ates. If YES, i nitial here: ____________

ORGAN

DONOR

Would you like t o be an organ donor and have that infor m ation on your license or i dentif ication card?

 YES  NO

If you are at leas t 16 and less t han 18 years old, a parent or guardi an may s ign the affidavit to ensur e your wishes are followed.

Would you like t o donate $1 or more to the anat om ical gift accoun t? If so, how much? $_______________

Have you ever had a driver’s license or identification card in another name?  YES  NO

UNDER W HAT NAME WAS IT ISSUED?

Have you ever had a driver’s license or identification card in another state?  YES  NO What stat e? _____________________

Is t he card in your possession?

 YES  NO License No. _____________________ Class/Type _______ Expiration Dat e ___________________

Has your driving pri vil ege ever been revoked, suspended, c ancel ed or denied? 

YES



If yes, State _____________ Date ______________ Reason ___________________________________________________________________________

Do you have any disabil ity, illness, missing extremity, or take any medicat i on that could affect your driving ability?



YES



If yes, pleas e expl ai n ___________________________________________________________________________________________________________

If you wish, some medic al conditions may be indicat ed on your DL/DAC/ID. Form DLD7 must be completed by your physician.

- CONTINUED ON BACK -

Visi on Ac uity: Left Both Right

Office Use Only

Ind. ID # ___________________________________

With OR Wi thout Correction: 20/___ 20/___ 20/___  Written Reinstat emen t I nfo ___________________________

PDPS/CDLIS:  Clear  Hit W/D:_____ Cites: _____  2

Hit  Drive Restrictions ________________________________

St ate:_______________ DLN:_________________________ Score(s) _______________________________________________________

Docs / Notes:________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

DMV-002 (Rev. 8/2015 )

Affidavits and Signatures Must be Witnessed by an Authorized DMV Representative

AFFIDAVIT

INITIAL

CONSENT FOR MINOR’S LICENSE

I, the undersigned, do hereby consent to the issuance of an instruction permit/license to__________________________,

whose relationship to me is _______________________. I understand that I can be held responsible for any liability c aused

by his/her negligence or willful misconduct in the operation of a motor vehicle (NRS 483.300 and/or NRS

486.101). I

understand that I m ay have the permit/license canc elled and be released from liability by signing a cancel lation request at a

DMV Field Services Office. I also understand that before a license is issued, the minor may need to present a DMV-301

Certification of Attendance, a Certificate of Completion from a Nevada DMV-

approved Driver Education Course and a

DLD-130 Beginning Driver Experience Log, to the DMV attesting he/she has completed at least 50 hours of behind-the-

w heel driving experience.

INSTRUCTION PERMIT

I, the undersigned, do hereby certify that I understand my instruction permit is valid for up to one (1) year from date of

issuanc e and I must carry it with me when I am drivi ng. I understand the restrictions on my permit and agree to follow them.

MINOR ORGAN DONOR

I, parent/guardian of minor applicant, understand that unless the anatomical gift is amended or revoked by the donor before

his/her death, I may not amend or revoke the anatomical gift. _____________________________________________

Signature

NON-U SE OF NE VAD A DR IVIN G PR I VIL EGE

I, the undersigned, do hereby certify that I have not operated any motor vehicle since ____________________________.

Date

NO SOCIAL SECURITY NUMBER

I, the undersigned, do hereby certify that I have never been assigned a Social Security Number under the provisions of the

Soci al Security Act of the United States .

DISCL OSURE STATEMENTS

• The Privacy Act of 1974 is a federal law that authorizes use of your Social Security Number to verify identity. You are required to

submit your Soci al Securi ty Number so the state may administer laws related to licensing dr i v ers (NRS 483.290).

• The driver’s license or identification card application you are

submitting will cause any driving record from your previous state to be

transferred to Nevada. Due to your change of residency, the license or identificati

on card in your previous state will show as

surrendered.

• NRS 482.385 requires you to register each vehicle you own and operate now or wi thin 30 days of becoming a resident.

I hereby certify, under penalty of perjury, that all statements in this application are true and correct. I understand

that

any and all other driver’s license or identification cards issued by any other jurisdiction will be surrendered

upon issuance of a Nevada license or identification card. I agree and understand that any misstatement of material

facts m ay cau se can cella tion and/or den ial of my li cense or ident ifi cation c ard u nder N RS 483 .420 an d NR S 483. 530,

respectively. I further understand that any

misstatement of facts may be a misdemeanor or felony under NRS

483.530 and may be punishable pursuant to NRS 193.130.

Applicant Signat ur e Date

Parent/Guardian Signature if Applicant is Under 18 DL/DAC/ID No.

Sworn Before Me This D ay of , 20

Authorized DMV Representative ______________________________________________ Tech ID _________________

Signatures must be originals. Photocopies are not acceptable. Changes may not be made to this form once signed.