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Fillable Printable Form MV-44EDL - Application for Enhanced Permit, Driver License or Non-Driver ID Card - New York

Fillable Printable Form MV-44EDL - Application for Enhanced Permit, Driver License or Non-Driver ID Card - New York

Form MV-44EDL - Application for Enhanced Permit, Driver License or Non-Driver ID Card - New York

Form MV-44EDL - Application for Enhanced Permit, Driver License or Non-Driver ID Card - New York

(mark all that apply):
MARK THE BOX OF THE TYPE OF DOCUMENT OR SERVICE YOU NEED
MV-44EDL (5/15)
o
ooooo
Learner
Permit
o
Upgrade Current
Document to EDL
ID
card
Renewal Replacement
Change
NYS license in exchange for a license from another US
State, the District of Columbia or Canadian Province
This form is also available at www.dmv.ny.gov
PRINT CLEARLY IN BLUE OR BLACK INK.
Other
Restrictions
License
Class
Special
Conditions
Endorsements
F
O
R
O
F
F
I
C
E
U
S
E
ADDRESS WHERE YOU GET YOUR MAIL
- Include Street Number and Name, Rural Delivery and/or box number (If you have a PO box, also fill in “Address Where You Live” below)
ADDRESS WHERE YOU LIVE
REQUIRED IF DIFFERENT FROM ADDRESS FOR MAIL - DO NOT GIVE P.O. BOX. THIS ADDRESS WILL APPEAR ON YOUR DRIVER LICENSE.
APPLICATION FOR ENHANCED PERMIT, DRIVER LICENSE
OR NON-DRIVER ID CARD
PLEASE COMPLETE AND SIGN PAGE 2.
Month Day Year
* 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.
What is the change and the reason for it (new
license class, wrong date of birth, etc.)?
OTHER CHANGE:
Male Female
oo
FULL LAST NAME
FULL FIRST NAME
FULL MIDDLE NAME
SUFFIX
DATE OF BIRTHSEXHEIGHT
EYE COLOR
SOCIAL SECURITY NUMBER
*(SSN)
DAY PHONE NO.
Do you have or did you ever have a driver license that is valid or that
expired within the last two years, issued by another US State, the
District of Columbia or a Canadian Province?
oYes oNo
If “Yes”, where was it issued? ____________________________
Date of Expiration: Type of License: Out-of-State License ID No.:
Area Code
( )
Apt. No.City or TownStateZip Code
Apt. No.City or TownStateZip Code
County
County
Feet Inches
}
IDENTIFICATION INFORMATION
NYS DRIVER LICENSE, LEARNER PERMIT, or
NON-DRIVER ID CARD NUMBER
If “Yes”, enter the identification number as it appears
on the license, learner permit, or non-driver ID card.
¦
Driver license? . . . . .oYes oNo
Learner permit?. . . .
oYes oNo
Non-driver ID Card?
oYes oNo
Do you now have, or did you ever have a New York:
If “Yes”, print your former name
exactly as it appears on your present license or non-driver ID card.
Has your name changed?
oYes oNo
Email Address: (optional)
Has your mailing address changed? oYes oNo
Has the address where you live changed?
oYes oNo
(Please answer “yes” or “no”.)
VOTER REGISTRATION QUESTIONS
NEW YORK STATE ORGAN AND TISSUE DONATION
Check 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.
o
Donor Consent Signature:ç________________________________________________________________ Date:_____________
SM
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 check 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 be applying in person at a DMV office).
o
o
NO - I Decline to Register/Already Registered/I do not want to notify
the Board of Elections of my change of address.
VETERAN STATUS
Check this box if you would like to have “Veteran” printed on the front of your photo document.
To enroll in the NYS Department of Health’s Donate Life Registry, check the “yes” box and then sign and date below. You are certifying
that you are: 18 years or older; consenting to donate all of your organs and tissues for transplantation, research or both; authorizing DMV
to transfer your name and identifying information to DOH for enrollment in the Registry; and authorizing 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
provide you an opportunity to limit your donation.
o
o
o
(You must fill out the following section)
You must present proof that indicates an honorable discharge from military service. For additional information, please see form MV-44.1.
You must answer the following question
: Would you like to be added to the Donate Life Registry?
Yes (sign and date consent below)
Skip This Question
PAGE 1 OF 3
Image #
OFFICE USE ONLY
A B C NCDL-C D DJ
E ID M MJ
AM DP LR TR LS BC
ML NF TD UC UP UR X8 XT
oBirth Certificate
oU.S. Passport
oForeign Passport
oDriver License/ID
oLearner Permit
oMV-45
oOut of-State-License
oDHS Document(s)
oMedical Certificate (CDL Only)
oImage Retrieval
oSocial Security Card
oCredit Card
oATM Card
Other:
NI NA EI EA
Proof Submitted:
Approved By Date
Office
oTEENS
oLicense/Permit
Surrendered for
Non-Driver ID Card
CDL Certifications
CERTIFICATION
MV-44EDL (5/15)
PAGE 2 OF 3
PRINT
NAME
My signature authorizes____________________________________________
to use my credit card for payment of any fees in connection with this application and I
understand that I must be present for this transaction.
Sign
Here
ç
(Cardholder-Sign Name in Full)
I certify that the information I have given on this application is true. I certify that I am a citizen of the United States of America and a resident of
New York State. If I am applying for a replacement license or non-driver identification card, I certify that the license or nondriver identification card has been lost,
stolen or mutilated and that, if the lost license or non-driver identification card is found, I will turn it in to the Department of Motor Vehicles. If I am exchanging my
out-of-state license for a NYS license, I certify that I was a permanent resident of the state or province in which my license was issued at the time the license was
issued, that such license has been valid for at least 6 months, and that I have not failed a road test in NYS in the last 12 months. 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.
I understand that the information and documentation that I have provided in connection with this application will be used to verify my identity, New York State
residency and United States citizenship. I understand that this information and documentation will be shared with the New York State and United States federal
entities for these verification purposes and I consent to this dissemination and use.
CREDIT CARD AUTHORIZATION IF CARDHOLDER IS NOT THE APPLICANT:
TEST RESULTS
Eye
oPass oCorrective Lens
1
2
Written
oPass oFail
Applicant’s Signature
Examiner’s Initials
ç
SIGN HERE ç
O
F
F
I
C
E
U
S
E
oJunior License oNon-driver ID Card (under 16)
I am the parent or guardian of the applicant, and I consent to the issuance of a learner permit, license or (if under 16) a non-driver ID card to him/her. I
understand that I am responsible for certifying that the applicant has completed at least 50 hours of supervised “practice” driving, including 15 hours of driving
after sunset, prior to the applicant taking a road test, and that this certification (MV-262) must be presented at the time of the road test. Note to parent/guardian:
If the driver license applicant is 17 years old and has a Driver Education Student Certificate of Completion (MV-285), consent is not required.
Parent or Guardian
Sign Here
ç
(Relationship to Applicant)(Date)
PARENT/GUARDIAN CONSENT
I would like to enroll in the TEENS program to be notified if the under 18 year-old applicant
receives a conviction, suspension, revocation or an accident on their license file. For more
information about this program, see form MV-1046, How to Enroll in TEENS or MV-1056,
TEENS FAQs. This is a FREE service.
Teen Electronic Event Notification Service (TEENS)
NYS Client ID of Consenting Parent or Guardian Above- Required
DRIVER LICENSE and LEARNER PERMIT APPLICANTS ONLY
COMMERCIAL DRIVER LICENSE APPLICANTS ONLY
1. In the past 10 years, was a driver license issued to you from another state in the U.S. or the District of Columbia ?oYes oNo
If YES, write the name of each one (if you turn in a license from another state, do not include that state):
1.Has your driver license, learner permit, or privilege to drive a motor vehicle been suspended, revoked or cancelled, or has your application for a license been
denied in this state or elsewhere, in the name you provide on this form or any other name? oYes oNo
If “Yes”, has your license, permit or privilege been restored, or has your application been approved? oYes oNo
2.Have you received treatment, do you currently receive treatment, or do you take medication for any condition that causes unconsciousness or unawareness
(for example, a convulsive disorder, epilepsy, fainting or dizziness, or a heart condition)? oYesoNo
If you marked “Yes”, you must submit form MV-80U.1, even if you were released from the Medical Review Program. You can get this form at any Motor
Vehicles office or at www.dmv.ny.gov.
3. Do you need a hearing aid and/or full view mirror to drive a motor vehicle? oYesoNo
4. Have you lost the use of a leg, arm, hand or eye? oYesoNo
4a. If you need to renew your driver license and you marked “Yes”, did this occur since your last driver license? oYesoNo
4b. If you marked “NO” to 4a, has your condition gotten worse since your last driver license? oYesoNo
IMPORTANT: Making a false statement in any license or non-driver ID card application, or in any proof or statement in connection with it, or
deceiving or substituting, or causing another person to deceive or substitute in connection with such application, may subject you to criminal
prosecution for a misdemeanor or felony under the Vehicle and Traffic Law and/or the Penal Law.
2.You MUST certify to DMV that you operate (or expect to operate) a commercial motor vehicle in one of the following four driving types (select only one):
oNon-excepted Interstate (NI) - Certified medical status is required. You are age 21 or older and you operate, or expect to operate, interstate (other than
for excepted operation).
oExcepted Interstate (EI) -You are age 18 or older and you operate, or expect to operate, interstate in Excepted Operation ONLY. You must have A3 restriction.
oNon-excepted Intrastate (NA) -Certified medical status is required. You are age 18 or older and you operate, or expect to operate, in NYS only (other
than for excepted operation).
oExcepted Intrastate (EA) - You are age 18 or older and you operate, or expect to operate, in Excepted Operation ONLY and in NYS ONLY. You must have A3
and K restrictions.
If the driving type you selected requires certified medical status (NI or NA) you must provide a legible copy of your current USDOT Medical Examiner’s
Certificate to DMV if it is not already on file. Please see DMV form MV-44.5 if additional information is needed to help you determine your driving type.
PAGE 3 OF 3
MV-44EDL (5/15)
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 partychange 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
l
be a U.S. citizen;
l
be 18 years old by the end of this year;
l
not be in prison or on parole for a felony conviction;
l
not claim the right to vote elsewhere
l
l
l
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.
MV-44EDL (5/15)
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?
oYesoNo
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.?
oYesoNo
If you answer NO, you cannot register to vote
Will you be 18 years of age or older on or before election day?
oYesoNo
If you answer NO, you cannot register to vote unless you will be 18 by the end of the year.
X
DateSign
AFFIDAVIT: I swear or affirm that
lI 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.
I wish to enroll in a political party:
oDemocratic party
oRepublican party
o Conservative party
oGreen party
oWorking Families party
oIndependence party
oWomen’s Equality party
oReform party
oOther _________________
I do not wish to enroll in a political party
oNo party
Political Party
Telephone Number (optional)
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.
reset/clear
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