Fillable Printable 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

TO VOTE?

yes—please complete new voter form

(provided by Dmv).

no—Do not complete voter form.

VOTER

CHANGE

ADDRESS

i am a registered voter. i have moved and wish to update my voter record:

to a new county—please complete a new voter form (provided

by Dmv).

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

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.)