Driving License Application Form

Applying for

Purpose for application

Driver ID

If known

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone number

Format: (000) 000-0000.

Birthdate

Date

Are you older than 18?

Place of birth

Gender

Are you currently holding a license issued by another country?

Issuing country

Driving license no.

Have you obtained your current foreign driving license by exchanging a license from another country?

Issuing country of original license

Driving license no. of original license

Categories to be applied for

Has your driving license, learning permit, or privilege to drive a motor vehicle been suspended, revoked, or cancelled, or has your application for a license has been denied?

If 'yes', has your license, permit, or privilege been restored, or has your application been approved?

Have you received treatment, do you currently receive treatment, or do you take medication for any condition that causes unconsciousness or unawareness? (for example, epilepsy, fainting, or dizziness?)

If 'yes', please specify

Do you need to wear glasses or lenses to drive a motor vehicle?

Do you need hearing aid to drive a motor vehicle?

Have you lost the use of a leg, arm, hand, or an eye?

Organ/Tissue Donation

Parent/Guardian Consent

As the parent/guardian of the applicant, I consent to the issuance of a learning permit or a driving license for the applicant. I understand that I am responsible for certifying that the applicant has completed the minimum required hours of supervised practice driving.

Parent/Guardian Name

First NameLast Name

Date

Signature

Certification

I certify that information given in this application and on any documentation provided in support of this application is true and complete.

I understand that making a false statement on this application, or submitting any documentation supporting this application that is false, may be punishable as a criminal offense.

Date

Signature