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Fillable Printable Driving Licence Renewal Form - California

Fillable Printable Driving Licence Renewal Form - California

Driving Licence Renewal Form - California

Driving Licence Renewal Form - California

CALIFORNIA DRIVER LICENSE
RENEWAL BY MAIL ELIGIBILITY INFORMATION
704
You must provide your Social Security Number and be under age 70 when your current license expires to renew by mail. If you answer
YES to any question in Section 1 of this form, Stop and call your local DMV office for an appointment to renew in person. If you answer
No to all questions in Section 1, please complete Sections 2-5.
SECTION 1 — ARE YOU ELIGIBLE FOR RENEWAL BY MAIL? (please answer the questions below to determine eligibility.)
YES NO
G. WIThIN ThE pAST TWO YEARS:
YES NO
A. Have your last two licenses been renewed by mail? ................
B. Has your license been expired for more than one year? ..........
C. Does your license expire more than 60 days from today? .......
D. Are you currently on any type of driving probation? ................
E. Are you changing/correcting your name? ................................
F. Within the past 5 years, have you had any problems with, or changes
to, your health or vision that affect your ability to drive safely? (See
medical information in Section 7 below before responding.) .......
Were you convicted of any Vehicle Code moving
violations? ......................................................................
• DidyoufailtoappearincourtforanyVehicleCodemoving
violation? ........................................................................
• Wereyoususpendedfordrivingundertheinuence,orfor
refusing, or failing to complete a chemical or preliminary
alcohol screening (PAS) test? .........................................
• Haveyoubeenatfaultinoneormorecollisions,asreported
by law enforcement? ......................................................
H. Do you have a driver license from more than one state or
jurisdiction? ........................................................................
SECTION 2 — pLEASE TELL US ABOUT YOURSELF (Use your true full name.)
Driver License or iD carD number state or country expiration Date
m m / D D / y y y y
Last name birth Date
m m / D D / y y y y
First name miDDLe name suFFix (Jr., Sr., III)
resiDentiaL street (Where you lIve) number, street name (St., Ave., rd., Blvd., etc.)
city state Zip coDe
maiLing aDDress (If dIfferent) number, street name (St., Ave., rd., Blvd., etc.) or p.o. box number
city state Zip coDe
MY SOCIAL SECURITY NUMBER IS:
SECTION 3 — ThE FOLLOWING QUESTIONS MUST BE ANSWERED IF YOU hAVE A COMMERCIAL DRIVER LICENSE
A. have you ever applied for a california driver license or identication card under a different name?
yes no if yes, provide name in the space provided.
First name miDDLe name Last name suFFix (Jr., Sr., III)
B. have you ever been issued a driver license under the same or a different name to operate any type of motor vehicle in another state or other
jurisdiction during the past ten years?
yes no if yes, you must complete the 10 year history record check form (DL 939) and attach it to
the application.
SECTION 4 — DO YOU WISh TO REGISTER TO VOTE OR ChANGE YOUR VOTER ADDRESS?
DO YOU
WISH TO
REGISTER
TO VOTE?
Y
yes—please complete new voter form
(provided by Dmv).
N
no—Do not complete voter form.
VOTER
CHANGE
OF
ADDRESS
i am a registered voter. i have moved and wish to update my voter record:
C
to a new county—please complete a new voter form (provided
by Dmv).
S
within the same county—Do not complete the voter form. your
voter record will be automatically updated.
if the voter has not received voter registration information within 30 days of requesting it, they should contact the Local elections office of the
office of the secretary of state.
SECTION 5 — hAVE YOU EVER SERVED IN ThE UNITED STATES MILITARY? (Read Veteran Statement in Section 7.)
i have served in the united states military and i want to receive veteran benets information.
SECTION 6 — DO YOU WISh TO REGISTER TO BE AN ORGAN AND TISSUE DONOR?
yes, add my name to the donor registry.
i do not wish to register at this time.
$2 voluntary contribution to support and promote organ and tissue
donation.
marking “yes” adds your name to the Donate Life california organ and
tissue Donor registry and a pink ‘donor dot will appear on your license.
if you wish to remove your name from the registry, you must contact
Donate Life california (see section 7); Dmv can remove the pink dot
from your licenses but cannot remove you from the registry.
STATE OF CALIFORNIA
DEPARTMENT OF MOTOR VEHICLES
®
A Public Service Agency
DL 410 Fo (rev. 1/2014) WWW
please continue on the next page.
DL 410 Fo (rev. 1/2014) WWW
SECTION 7 — CERTIFICATIONS AND IMpORTANT INFORMATION
• MedicalInformation—Examples of health or vision problems that must be reported are:
—Lossofconsciousnessormarkedconfusionexperiencedononeormoreoccasions.
any disease or disorder which may affect your ability to operate a motor vehicle safely upon a highway, such as: epilepsy, diabetes, stroke,
drug or alcohol addiction.
any vision change which could affect your ability to drive safely, such as: glaucoma, diabetic retinopathy, cataracts, macular degeneration.
• SocialSecurityNumberCollectionDisclosure—YouarerequiredbylawtoprovideyoursocialsecuritynumberoryourRenewalbyMail
application will be denied. authority to collect the social security number is 42 u.s.c. 405 and california vehicle code §1653.5, §4150, §4150.2,
§12800, and §12801. it will be used in the administration of driver license laws and motor vehicle registration laws and to respond to requests
forinformationfromtheFranchiseTaxBoardfortaxadministrationandfromanyagencyoperatingpursuantto42U.S.C.601etseq.Itwillbe
used to aid in the collection of monies owed in connection with failure to pay nes or failure to appear in court by an applicant, and to aid in the
collection of monies owed by an applicant in connection with aid to Families with Dependent children, child support, and/or establishment of
paternity.
• CaliforniastatelawallowstheStateBoardofEqualizationandtheFranchiseTaxBoardtosharetaxpayerinformationwiththeDMVandrequires
youtopayadelinquentstatetaxobligation.Failuretopaythisdelinquenttaxobligationmayresultinthesuspensionofyourdriverlicense.
• ChemicalTestDisclosure—Iagreetosubmittoachemicaltest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 peace officer acting in accordance with vehicle code §23612.
•
Organ Donor Statement — If you marked‘Yes to register as an organ and tissue donor, you are legally authorizing the recovery of
organs and tissues in the event of your death. registering as a donor will not affect your medical treatment in any way. as outlined in the
CaliforniaAnatomicalGiftAct,yourauthorizationislegallybindingand,unlessthedonorisunder18yearsofage,yourdecisiondoesnot
require the consent of any other person. For registered donors under 18 years of age, the legal guardian shall make the nal donation
decision.You may limit your donation to specic organs or tissues, place usage restrictions (for example transplantation or research),
obtain more information about donation, or remove your name from the registry on the internet Web site of Donate Life california:
www.donateLIFEcalifornia.org. by registering as an organ Donor, you are giving your consent to allow Dmv to electronically transmit your
true full name, residence or mailing address, year of birth, and california driver license or identication card number to Donate Life california.
by signing this form you consent to this process and have been notied that this transmission will occur.
• VeteranStatement—
Bymarkingtheveteranboxonthisapplication,IcertifythatIamaveteranoftheUnitedStatesArmedForcesandthatI
wanttoreceiveveteranbenetsinformationfromtheCaliforniaDepartmentofVeteransAffairs.Bymarkingtheveteranboxonthisapplication,
i also consent to Dmv transmitting my name and mailing address to the california Department of veterans affairs for this purpose only, and
i certify that i have been notied that this transmittal will occur.
• CerticationStatement—Iamherebyadvisedthatbeingundertheinuenceofalcoholordrugs,orboth,impairstheabilitytosafelyoperate
amotorvehicle.Therefore,itisextremelydangeroustohumanlifetodrivewhileundertheinuenceofalcoholordrugs,orboth.IfIdrive
whileundertheinuenceofalcoholordrugs,orboth,andasaresult,apersoniskilled,Icanbechargedwithmurder.
by signing this application, i certify that i was notied that if i am under 21 years of age, i cannot legally drive with a blood alcohol concentration
(bac) of 0.01% or more. Driving with a bac of 0.01% or more, or refusing to take, or failing to complete an alcohol screening or drug test,
results in a one-year suspension of my driving privilege.
— Bysigningthisapplication,IcertifythatIwasnotiedthatifIamcurrentlyoncourtprobationforadrivingundertheinuenceoffense,I
cannot legally drive with a blood alcohol concentration (bac) of 0.01% or more. Driving with a bac of 0.01% or more results in a one-year
suspension of my driving privilege. refusing to take, or failing to complete an alcohol screening or chemical test will result in a two to three
year suspension/revocation of my driving privilege.
— Bysigningthisform,IamacknowledgingmypresenceintheUnitedStatesisauthorizedunderfederallaw.
i understand i may have no more than one driver license in my possession or under my control in accordance with california vehicle code
§12511.
Dmv checks for driving record status in other jurisdictions through the national Driver registry prior to issuance of a california driver license.
you will not be issued a california driver license if another jurisdiction has withdrawn your driving privilege.
i understand Dmv may add traffic convictions reported by other states or jurisdictions to my driving record that may result in sanctions against
my california driving privilege.
by signing this application, i certify that i understand traffic signs and signals in accordance with california vehicle code §12800(h).
• MailingAddress—IamthepersonwhosenameappearsinSection2ofthisform.Themailingaddressshownisvalid,existing,andaccurate.
i consent to receive service of process at this mailing address pursuant to §415.20(b), §415.30(a), and §416.90 of the civil procedure code.
• AdvisoryStatement—TheinformationrequiredonthisformpertainstoeligibilityunderthePublicRecordsAct.Thisinformationisapublic
record and is regularly used by law enforcement agencies and insurance companies. access to address information is now restricted, and will
beavailabletovariousauthorizedrequestersforlimited use. individuals can obtain copies of their own information during regular office hours.
SECTION 8 — SIGNATURE/pERJURY STATEMENT
I have read, understand and agree with the certications on this document. I certify (or declare) under penalty of perjury under the
laws of the State of California that the foregoing is true and correct.
signature
X
Dat e
SECTION 9 — WhERE TO MAIL
Therenewalfeeforbasicdriverlicenseis$33.00or$41.00forCommercialLicenses.Ifyoumarkedtheboxtomakea$2voluntarycontribution
to support and promote the Donate Life california organ and tissue donor registry, include the $2 voluntary contribution with your check or money
order made payable to Dmv and mail this form to:
DMV, Attn: Renewal By Mail Unit
pO Box 942890
Sacramento, CA 94290-0001
(please write your driver license number on the back of your payment document.)
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