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

(mark all that apply):

MARK THE BOX OF THE TYPE OF DOCUMENT OR SERVICE YOU NEED

MV-44EDL (5/15)

oo o o o

Learner

Permit

Upgrade Current

Document to EDL

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

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

FULL LAST NAME

FULL FIRST NAME

FULL MIDDLE NAME

SUFFIX

DATE OF BIRTH SEX HEIGHT

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?

o Yes o No

If “Yes”, where was it issued? ____________________________

Date of Expiration: Type of License: Out-of-State License ID No.:

Area Code

( )

Apt. No. City or Town State Zip Code

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? . . . . . o Yes o No

Learner permit? . . . .

o Yes o No

Non-driver ID Card?

o Yes o No

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?

o Yes o No

Email Address: (optional)

Has your mailing address changed? o Yes o No

Has the address where you live changed?

o Yes o No

(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.

♥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 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).

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.

(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

o Birth Certificate

o U.S. Passport

o Foreign Passport

o Driver License/ID

o Learner Permit

o MV-45

o Out of-State-License

o DHS Document(s)

o Medical Certificate (CDL Only)

o Image Retrieval

o Social Security Card

o Credit Card

o ATM Card

Other:

NI NA EI EA

Proof Submitted:

Approved By Date

Office

o TEENS

o License/Permit

Surrendered for

Non-Driver ID Card

CDL Certifications

CERTIFICATION

MV-44EDL (5/15)

PAGE 2 OF 3

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

(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

o Pass o Corrective Lens

Written

o Pass o Fail

Applicant’s Signature

Examiner’s Initials

SIGN HERE ç

o Junior License o Non-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

(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 ? o Yes o No

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? o Yes o No

If “Yes”, has your license, permit or privilege been restored, or has your application been approved? o Yes o No

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)? o Yes o No

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? o Yes o No

4. Have you lost the use of a leg, arm, hand or eye? o Yes o No

4a. If you need to renew your driver license and you marked “Yes”, did this occur since your last driver license? o Yes o No

4b. If you marked “NO” to 4a, has your condition gotten worse since your last driver license? o Yes o No

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):

o Non-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).

o Excepted 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.

o Non-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).

o Excepted 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 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

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?

o Yes 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 Yes 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 Yes o No

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

DateSign

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.

I wish to enroll in a political party:

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 Reform party

o Other _________________

I do not wish to enroll in a political party

o No 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.

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