Driving License Application Form

Applying for

Learning PermitDriving License

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

Birthdate

Date

Are you older than 18?

YesNo

Place of birth

Gender

MaleFemaleOtherPrefer not to answer

Are you currently holding a license issued by another country?

YesNo

Issuing country

Driving license no.

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

YesNo

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?

YesNo

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

YesNo

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?)

YesNo

If 'yes', please specify

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

YesNo

Do you need hearing aid to drive a motor vehicle?

YesNo

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

YesNo

Organ/Tissue Donation

When you check the box, you are consenting to donate your organs and tissues for transplantation and research, upon your death.

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