Fillable Printable Form MV-44CR - Restricted Use or Conditional Driver License Application - New York

Form MV-44CR - Restricted Use or Conditional Driver License Application - New York

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MV-44CR (12/14)

Case

No.

Order

No.

LAM LRN LDP LNO

D DJ E M MJ NCDL-C

AM CL DP IL

LR NF RL

New York State Department of Motor Vehicles

RESTRICTED USE OR CONDITIONAL

DRIVER LICENSE APPLICATION

Stop/Response Validation Number

License

Class

Special

Conditions

Restrictions

Exp. Date

Fee

Proof Submitted

Approved By Date

Office

oBirth Certificate o Driver License/ID

oCredit Card o Passport

oINS Papers o Image Retrieval

oSocial Security Card

Other:

PLEASE COMPLETE AND SIGN PAGE 2.

Eye Test o Pass o Corrective Lens

IMPORTANT: You cannot use a restricted use license to drive a vehicle for hire, unless your license is suspended or revoked because of an uninsured accident,

an insurance lapse, uninsured operation of a motor vehicle, or for delinquent child support payments. You cannot use a restricted use license to operate a

commercial vehicle. You cannot use a conditional license to drive a commercial vehicle or a vehicle for hire.

PLEASE PRINT CLEARLY IN BLUE OR BLACK INK.

o Apply for a restricted

use license

o Replace a restricted use or

conditional license

o Renew a restricted use or

conditional license

o Apply for a

conditional license

o Change information on a

restricted use or conditional license

MARK THE BOX OF THE TYPE OF SERVICE YOU NEED (YOU CAN MARK MORE THAN ONE)

MV-44CR (12/14)

* You must provide your SSN. Authority to collect your SSN is granted by Sections

490.3 and 502 of the Vehicle and Traffic Law. The information will be used only for

exchange with other jurisdictions, to assist in verification of identity, and to invoke

driver license sanctions pursuant to V&T Law Section 510(4-e) and 510(4-f). Your

number will not be given to the public, or appear on any form or information request.

SOCIAL SECURITY NUMBER* (SSN)

NYS DRIVER LICENSE OR NON-DRIVER ID CARD NUMBER

FULL LAST NAME

FULL FIRST NAME

FULL MIDDLE NAME

Month Day Year

Male Female

SUFFIX

DATE OF BIRTH SEX HEIGHT

EYE COLOR

DAY TELEPHONE (Optional)

Area Code

( )

Feet Inches

ADDRESS WHERE YOU GET YOUR MAIL

Apt. No. City or Town State Zip Code

- Include Street Number and Name, Rural Delivery and/or box number (If you have a PO Box, also fill in “Address Where You Reside” below)

ADDRESS WHERE YOU RESIDE

Apt. No. City or Town State Zip Code

County

IF DIFFERENT FROM YOUR MAILING ADDRESS - DO NOT GIVE A P.O. BOX.

What is the change and the reason for the change

(new license class, wrong date of birth, etc.)?

OTHER CHANGE:

If “Yes”, print your former name exactly as your former name

appears on your present driver license or non-driver ID card.

Has your name changed?

o Yes o No

Has the address where

you get your mail changed?

o Yes o No

Has the address where you live changed? o Yes o No

(Please mark “yes” or “no”.)

VOTER REGISTRATION QUESTIONS

NEW YORK STATE ORGAN AND TISSUE DONATION

Mark this box to make a $1

voluntary contribution to the Life...Pass

It On Trust Fund. The $1 donation will

be added to your total transaction fee. A

contribution to the Fund is used for

organ donation and transplant research

and educational projects promoting

organ and tissue donation.

♥Donor Consent Signature: ç ____________________________________________________ Date:__________________

If you are not registered to vote where you live now, would you like to apply to register, or if you are changing your address, would you like the Board of Elections to be notified?

NOTE: If you do not mark either box, you will be considered to have decided not to register to vote.

YES - Complete Voter Registration Application Section

(Not necessary if you will apply in person at a DMV office).

NO - I Decline to Register/Already Registered/I do not want to notify

the Board of Elections of my change of address.

VETERAN STATUS

Mark this box to have “Veteran” printed on the front of your photo document.

To enroll in the NYS Department of Health’s Donate Life Registry, mark the “yes” box then sign and date below. You are certifying that

you: are age 18 or older; consent to donate all of your organs and tissues for transplantation, research or both; authorize DMV to

transfer your name and identifying information to DOH for enrollment in the Registry; and authorize DOH to allow access to this

information to federally regulated organ donation organizations and NYS-licensed tissue and eye banks and hospitals, upon your death.

“ORGAN DONOR” will be printed on the front of your DMV photo document. You will receive a confirmation from DOH, which will also

give you an opportunity to limit your donation.

You must answer the following question

: Would you like to be added to the Donate Life Registry? Yes Skip This Question

o o

(You must fill out the following section)

You must present proof of honorable discharge from military service. For more information, refer to form MV-44.1.

IDENTIFICATION INFORMATION

NEW YORK STATE VOTER REGISTRATION APPLICATION

Only

fill this out if you want to register to vote or change your address or other information with the Board of Elections.

If you register to vote, your completed voter registration application will be sent directly to the Board of Elections. If you decline to register, your decision will

remain confidential. You will be notified by your County Board of Elections when your voter registration application has been processed.

Have you voted before?

o Ye s o No

What Year?

Your name was

Your address was

Voting information that

has changed:

skip if this has not changed or

you have not voted before.

Your state or NYS

County was:

Are you a citizen of the U.S.?

o Ye s o No

If you answer NO, you cannot register to vote

Will you be 18 years of age or older on or before election day?

o Ye s o No

If you answer NO, you cannot register to vote unless you will be 18 by the end of the year.

Sign

AFFIDAVIT: I swear or affirm that

l I am a citizen of the United States.

l I will have lived in the county, city, or village for at least 30 days before the election.

l I meet all requirements to register to vote in New York State.

l This is my signature or mark on the line below.

l The above information is true, I understand that if it is not true, I can be convicted and fined up to $5,000 and/or

jailed for up to four years.

Political Party

Telephone Number (optional)

o Democratic party

o Republican party

o Conservative party

o Green party

o Working Families party

o Independence party

o Women’s Equality party

o StopCommonCore party

o Other (write in) ____________

o I do not wish to enroll in a party

You must make 1 selection

To vote in a primary

election, you must be

enrolled in one of these

listed parties - except the

Independence Party, which

permits non-enrolled voters

to participate in certain

primary elections.

CERTIFICATION - I state that the information I have given on this application is true to the best of my knowledge. If I am applying for a

replacement license, I certify that the information I have given on this application is true. If I am applying for a replacement license, I certify

that the license has been lost, stolen or mutilated and that, if the lost license is found, I will turn it in to the Department of Motor Vehicles. I

will pay the full tuition and other required fees for the rehabilitation program (if applicable), attend the program (if required), and will drive

within the conditions required for the restricted or conditional license. I understand that failure to do so will result in the revocation of my

restricted or conditional license, and the reinstatement of the suspension or revocation against my full license. If I am a male at least 18 but

less than 26 years old, I consent to be registered with the Selective Service System, if so required by federal law, and authorize the

forwarding of any personal information required for such registration. My signature below also authorizes use of my credit card, if applicable.

1. Have you had, or are you currently receiving treatment or taking medication for any condition which causes unconsciousness or unawareness such as

convulsive disorder, epilepsy, fainting or dizzy spells, or heart ailment?

o Yes o No

If “Yes”, you and your doctor must complete form MV-80U.1, even if you have been released from the Medical Review Program. This form can be obtained

at any Motor Vehicles office or at www.dmv.ny.gov.

2. Do you need a hearing aid or full view mirror while operating a motor vehicle? o Yes o No

3. Have you lost use of a leg, arm, hand or eye?

o Yes o No

3a. If you are renewing your license and answered “Yes”, is this a new condition since your last license? o Yes o No

3b. If you answered “NO” to 3a, has your condition worsened since your last license?

o Yes o No

MV-44CR (12/14)

IMPORTANT: Making a false statement in any license application or in any proof or statement in connection with it, or deceiving or

substituting, or causing another to deceive or substitute in connection with such application, is a misdemeanor under Section 392

of the Vehicle and Traffic Law, and may result in the revocation or suspension of your license.

HOW TO APPLY FOR A RESTRICTED USE OR CONDITIONAL DRIVER LICENSE

Follow the instructions below that apply to you. You must apply in person. You can do this at most, but not all, Motor Vehicles offices. Contact the nearest office to

find out where you can apply.

TO APPLY

for a

restricted

use or

conditional

license

1. Complete both sides of this application and sign your name in the “Certification” box.

2. Present this application and proof of identity. Refer to form ID-44 “Proofs of Identity” for a list of acceptable documents that you can show for proof.

3. Complete the Restricted Use License Attachment (form MV-693) or

the Conditional License Attachment (form MV-2020) if applicable, or any

additional forms provided by the Motor Vehicles office.

4. Pay the appropriate fee.

TO REPLACE

your restricted

use or

conditional

license

1. Complete both sides of this application and sign your name in the “Certification’ box. Your name, date of birth and sex must be entered

exactly as they were shown on your last license.

2. Present this application, and proof of identity. Refer to form ID-44 “Proofs of Identity” for a list of acceptable documents that you can show for

proof. To replace a mutilated license, turn in the license with this application.

3. Pay the appropriate fee.

4. If your Restricted Use License Attachment (form MV-693) or

Conditional License Attachment (form MV-2020) is lost, you must complete a

new attachment.

TO CHANGE

information

on your

restricted use

or conditional

license

1. Complete both sides of this application (use your new information), and sign your name in the “Certification” box.

2. Present this application, your current license, your Restricted Use License Attachment (form MV-693) or

Conditional License Attachment

(form MV-2020), proof of identity, and proof of the change that you need. Refer to form ID-44 “Proofs of Identity” for a list of acceptable

documents that you can show for proof.

3. Pay the appropriate fee.

TO RENEW

your restricted

use or

conditional

license

1. Complete both sides of this application, and sign your name in the “Certification” box.

2. Present this application, the Restricted Use License Attachment (form MV-693) or

Conditional License Attachment (form MV-2020),

your current license, and proof of identity. Refer to form ID-44 “Proofs of Identity” for a list of acceptable documents that you can show for proof.

3. Take a vision test in any Motor Vehicles office or have your vision tested by one of the following providers: licensed physician, physician

assistant, registered nurse, nurse practitioner, ophthalmologist, optometrist, optician, pharmacists who are enrolled in DMV’s Vision Registry, staff

supervised by any of these providers and the staff of organizations that are authorized by the New York State DMV to give the vision test.

4. Pay the appropriate fee.

(Sign name in full - A married woman must use her own first name.)

CREDIT CARD AUTHORIZATION IF CARDHOLDER IS NOT THE APPLICANT:

My signature authorizes _____________________________________________

to use my credit card for payment of fees in connection with this application, and I

understand that I must be present for this transaction.

Sign

Here

(Cardholder-Sign Name in Full)

MV-44CR (12/14)

SIGN HERE ç ________________________________________________________________________________________

OFFICE USE ONLY

NEW YORK STATE VOTER REGISTRATION APPLICATION INFORMATION

(Please read before you complete application on the other side.)

Use the NYS Voter Registration Application to Register to Vote in NYS Elections, and/or:

To Register You Must:

change the name or address on your voter registration

become a member of a political party change your party membership

If you decline to register, your decision will remain confidential. If you believe that someone has interfered with your right to register or decline to register to vote,

your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference,

you may file a complaint with the NYS Board of Elections, 40 Steuben Street, Albany, NY 12207-2109 (phone: 1-800-469-6872).

Your completed application will be sent to the Board of Elections and you will be notified by your County Board of Elections when your application has been

processed. If you have any questions about filling out the voter registration application or registering to vote, you should call your County Board of Elections or call

1-800-FOR-VOTE (TDD/TTY Dial 711) (only for voter registration questions). If you live in New York City, you should call 1-866-VOTE-NYC. You may also find

answers or tools at the NYS Board of Elections website: www.elections.ny.gov

be a U.S. citizen;

be 18 years old by the end of this year;

not be in prison or on parole for a felony conviction;

not claim the right to vote elsewhere