Fillable Printable ID Card Application Form - Virginia

ID Card Application Form - Virginia

NOTE: YOUR ADDRESS BELOW MUST BE CURRENT. THE U.S. POSTAL SERVICE WILL NOT FORWARD.

REMARKS/PAID STAMP

CUSTOMER NUMBER

PROOF OF LEGAL PRESENCE (specify)

Document Type Document Number Expiration Date (mm/dd/yyyy)

TRANSACTION TYPE

DOCUMENT VERIFIER SIGNATURE AND LOGONIDCSR SIGNATURE AND LOGONID

PROOF OF ID (primary)

PROOF OF SOCIAL SECURITY (specify)

PROOF OF ID (secondary)

PROOF OF RESIDENCY

GENDER (check one)

FEMALEMALE

HEIGHT

FT. IN.

WEIGHT

LBS.

NAME OF CITY OR COUNTY OF RESIDENCE

COUNTY OFCITY

SOCIAL SECURITY NUMBER BIRTHDATE (mm/dd/yyyy)FULL LEGAL NAME (last, first, middle, suffix)

EYE COLOR HAIR COLOR

IF YOUR NAME HAS CHANGED, PRINT YOUR FORMER NAME HERE

MAILING ADDRESS (if different from above - this address will show on your license/ID card) APT NO. CITY STATE ZIP CODE

Purpose: Use this form to apply for a Virginia Driver's License or Identification Card.

Instructions: Complete the front and back of this application. Note: A $5 service fee applies to each license or ID card renewal conducted in a CSC if the

transaction is eligible to be performed by internet, automated telephone or mail, unless the renewal is conducted with another transaction that

must be completed in person at a CSC.

Note: Va. Code §§46.2-323 and 46.2-342 require that you provide DMV with the information on this form (including your social security number). It is not necessary to provide a social security

number for an identification card. This social security number is for record keeping purposes and may be disseminated only in accordance with Va. Code §§46.2-208 and 46.2-209. Persons

convicted of certain sexual offenses (as listed in Va. Code §9.1-902) must register or re-register with the Virginia Department of State Police as provided in Va. Code §§9.1-901, 9.1-903, and

9.1-904. If you provide a non-Virginia residence/home address or non-Virginia mailing address, your application for a driver's license or identification (ID) card may be denied.

APPLICATION TYPE (Check one)

APPLICANT INFORMATION

DRIVER'S LICENSE AND IDENTIFICATION CARD APPLICATION

STREET ADDRESS APT NO. CITY STATE ZIP CODE

DL 1P (07/01/2015)

FOR DMV USE ONLY — DO NOT WRITE BELOW THIS LINE

Are you a citizen of the United States of America? Do you want to apply to register to vote or change your voter registration

address?

YES

(INITIAL BOX)

INFORMATION FOR THE DEPARTMENT OF ELECTIONS

Completion of this section is requested but not required to apply for a driver's license or ID Card. (Virginia Code §2.2-3806)

INFORMATION FOR THE VIRGINIA TRANSPLANT COUNCIL

Yes, I would like to remain or become an organ, eye and tissue donor.

YES

(INITIAL BOX)

LOG #

1. Driver's License

Learner's Permit and Driver's License

Motorcycle Learner's Permit (classification not applicable)

Driver's License with School Bus Endorsement

(to carry less than 16 passengers)

Driver's License Testing for Foreign Diplomats

Commercial Learner's Permit or License

Identification (ID) Card

Hearing Impaired ID Card

Emancipated Minor ID Card

Motorcycle Only License*New/Upgrade/Transfer Motorcycle Class*

Renew Virginia Motorcycle Class

10. Motorcycle

*Check one if New/Upgrade/Transfer or Motorcycle Only ---►

M ( both 2 wheels and 3 wheels) M 3 ( 3 wheels) M 2 ( 2 wheels)

I certify I cannot surrender my current license or ID card because it is:

I am surrendering my current license or ID card.

Destroyed or MutilatedStolen

Lost

11. Replacement license or identification card (check one of the following):

Do you currently have or have you ever held a driver's license, commercial driver's license or learner's permit from Virginia, another state, U.S. territory or

foreign country?

Yes -- provide the following:No

LICENSE NUMBER ISSUE DATE (mm/dd/yyyy) EXPIRATION DATE (mm/dd/yyyy) STATE/COUNTRY

DAYTIME TELEPHONE NUMBER

1. Do you wear glasses or contact lenses?

YES NO

2. Do you have a physical or mental condition which requires that you take medication?

YES NO

3. Have you ever had a seizure, blackout, or loss of consciousness?

YES NO

4. Do you have a physical condition which requires you to use special equipment in order to drive?

YES NO

5. Have you been convicted within the past ten years in this state or elsewhere of any offense

resulting from your operation of, or involving, a motor vehicle? (Do not include parking tickets.)

NOYES

6. Has your license or privilege to drive ever been suspended, revoked, or disqualified in this state

or elsewhere, or is it currently suspended, revoked or disqualified?

NOYES

SPECIAL INDICATOR REQUEST

Please show the following indicator(s) on my license

or ID card:

Insulin-dependent diabetic

Autism spectrum disorder (ASD)

Intellectual disability (IntD)

Hearing impairment (license only)

Speech impairment

Must submit required physician statement

If you answered YES to any of the above provide an explanation here.

REQUIRED TESTS

PASS FAIL

VISION

DL ROAD SIGNS EXAM

DL KNOWLEDGE EXAM

DL SKILLS

MOTORCYCLE KNOWLEDGE

MOTORCYCLE SKILLS M2

MOTORCYCLE SKILLS M3

RENEWALDUPLICATEREISSUEORIGINAL

FEE

APPLICANT UNDER AGE 18 Have you ever been found not innocent of any offense in a Juvenile and Domestic Relations Court in this or any other state?

YES NO

If you answered YES, a court within your jurisdiction must provide court consent below.

COURT CONSENT In my opinion the applicant's request for a learner's permit/driver's license

should be granted. should not be granted.

REMARKS:

PARENT/GUARDIAN NAME (print) PARENT/GUARDIAN SIGNATURE DATE (mm/dd/yyyy)

DATE (mm/dd/yyyy)JUDGE SIGNATURE JUDGE NAME (print)

GOVERNMENT EMPLOYEES - (Fee waiver certification)

I certify that I am employed by the:

to operate a motorcycle or commercial motor vehicle and, because of such employment, I am entitled to the waiver of the motorcycle class and/or

commercial motor vehicle endorsement fee, provided I have paid for and hold a valid Virginia driver's license or have made application for such.

County ofCommonwealth of Virginia or City of Town of

SELECTIVE SERVICE

All males under the age of 26 are required to check one of the following. Failure to provide a response will result in denial of your application.

By signing this application, I consent to be registered with Selective Service, if required by federal law. If under age 18, an appropriate adult must complete

and sign below: I authorize DMV to send information to Selective Service which will be used to register applicant when he is 18 years old.

I am already registered with Selective Service.

I am a non-immigrant alien in the U.S. and not required to register.

I authorize DMV to forward to the Selective Service System personal information necessary to register me with Selective Service.

SIGNATURE (check one and sign)

EMANCIPATED MINORPARENT/GUARDIAN JUDGE, JUVENILE DOMESTIC RELATIONS COURT

CERTIFICATION

I certify and affirm that I am a resident of Virginia, that all information presented in this application is true and correct, that any documents I have presented

to DMV are genuine, and that my appearance, for purpose of my DMV photograph, is a true and accurate representation of how I generally appear in public.

I make this certification and affirmation under penalty of perjury and understand that knowingly making a false statement on this application is a criminal

violation.

DATE (mm/dd/yyyy)APPLICANT SIGNATURE APPLICANT NAME (print)

Identify any state(s) in which you have

been previously licensed within the past

10 years. Provide additional information

using the Supplemental Driver's

Licensing History Sheet, form DL1PA.

Remove Endorsement(s) I want to remove the following endorsement(s) from my

license:

XTNH SP

Add Endorsement(s)

I want to apply for the following vehicle

endorsement(s):

H - Hazardous Materials

T - Double/Triple Trailer

X - Tank and Hazardous Materials

S - School Bus

P - Passenger Carrying Vehicle

(16 or more passengers)

N - Tank

STATE LICENSE NUMBER

LICENSE ISSUE DATE (mm/dd/yyyy)

LICENSE EXPIRATION DATE (mm/dd/yyyy)

VEHICLE TYPE

I want to be licensed to operate the type of vehicle(s) checked below:

A - Combination vehicle with GVWR or GCWR of 26,001 lbs. or more

B - Single vehicle with GVWR of 26,001 lbs. or more, or towing a

vehicle less than 10,000 lbs. GVWR.

C - Any vehicle that does not fit the definition of a Class A or Class B

vehicle and is either used to transport hazardous materials or

designed to carry 16 or more passengers, including the driver.

AIR BRAKES With (Full Air or Air Over Hydraulic) Without

(Check the

box for the

qualification

category that

applies).

INTERSTATE DRIVER INTRASTATE DRIVER

Requires an Intrastate Only restriction on the CDL (K)

NON-EXCEPTED - I meet the qualification requirements

under 49 CFR Part 391 of the Federal Motor Carrier Safety

Regulations. (Medical examiner's certificate required)

NON-EXCEPTED - I meet the qualification requirements

under Title 19 § 30-20-80 of the VA Administrative Code.

(Medical examiner's certificate required)

EXCEPTED - I am exempt from the qualification

requirements under 49 CFR Part 391 of the Federal Motor

Carrier Safety Regulations. (No medical examiner's

certificate required)

EXCEPTED - I am exempt from the qualification

requirements under Title 19 § 30-20-80 of the VA

Administrative Code. (No medical examiner's certificate required)

COMMERCIAL DRIVER'S LICENSE/LEARNER'S PERMIT APPLICANTS

PLACE OF DOMICILE - Your place of domicile may or may not be the same as your place of residence. Your place of residence is where you currently live

and your place of domicile is where your true, fixed and permanent home and principal residence is and to which you intend to return whenever you are

absent. My place of domicile is:

Virginia

Another U.S. state/territory or Canada/Mexico (not eligible - must apply

in place of domicle)

Outside of Virginia/Active Duty U.S. Military

(Active Duty Common Access Card (CAC) Required)

A country other than the U.S. (unexpired EAD or foreign passport and

I-94 required for a non-domiciled CLP/CDL)

PARENT OR LEGAL GUARDIAN LICENSE CONSENT

DL 1P (07/01/2015) -- Page 2

Check applicable box, review certification statement, print your name and sign where indicated.

I authorize issuance of a learner's permit/driver's license. I certify that the applicant is a resident of Virginia. I certify that the applicant is

attending school regularly and is in good academic standing, but if not, I authorize issuance of a learner's permit/driver's license. I certify that this

applicant will operate a motor vehicle for at least 45 hours (15 of which will occur after sunset) while holding a learner's permit.

If the applicant attends public school, I authorize the principal or designee of the public school attended by the applicant to notify the juvenile and

domestic relations district court (within whose jurisdiction the applicant resides) when the applicant has had 10 or more unexcused absences from

school on consecutive school days.

If a Special Indicator Request is checked on this application, I request on behalf of the applicant that it be shown on the learner's permit/driver's license.

I certify that the statements made and the information submitted by me are true and correct.

I authorize issuance of an ID card. If the applicant is under age 18, I certify that the applicant is a resident of Virginia. If a Special Indicator

Request is checked on this application, I request on behalf of the applicant that it be shown on the identification card.

I certify that the statements made and the information submitted by me are true and correct.