Application for License/Permit - Vermont
Application for License/Permit
DEPARTMENT OF MOTOR VEHICLES
Agency of Transportation
802.828.2000
dmv.vermont.gov
Complete both pages or form will be returned
I am Applying for a
(Check all that apply)
Driver’s
License (OPR)
Junior Driver’s
License (JUN)
Learner Permit (LRN)
Real ID Compliant
Original Issue
Transfer from Out of State
Privilege Card (Non-Real ID)
Renewal
Add Endorsement(s):
Enhanced (EDL)
Address Change
Other:
Vermont Identification Information - Do you now have, or did you ever have a Vermont:
Driver license?
Yes
No
Learner permit?
Yes
No
Non-driver ID Card?
Yes
No
If “Yes”, enter the identification number
as it appears on the license, learner
permit, or non-driver ID card
VERMONT LICENSE, PERMIT, or NON DRIVER ID CARD NUMBER
LAST NAME
Do you have a driver license that is valid or that expired within the
past year, issued by another US State, the District of Columbia or a
Canadian Province?
Yes
No
FIRST NAME
If “Yes”, where was it issued? ________________________________
MIDDLE NAME
Date of Expiration: License Type: License Number:
ADDRESS WHERE YOU GET YOUR MAIL
(mailing address)
- Include Street Number and Name (If PO or Private Box, also fill in “Address Where You Live” below)
City or Town State Zip Code
ADDRESS WHERE YOU LIVE
(physical address)
– This address will be printed on your license
City or Town State Zip Code
Social Security Number: Date of Birth (MM/DD/YYYY): Place of Birth (City, State & Country):
The disclosure of your social security or federal identification number is mandatory, is solicited by the authority granted by 42 U.S.C. § §405(c)(2)(C) and/or 666(a)(13) and
will be used by the Department of Motor Vehicles in the administration of motor vehicle, tax and child support laws, to identify individuals affected by such laws.
Gender:
Male
Female
Eye Color: Height: Weight:
Name, Address or Other Changes
If address change required for voter registration, complete voter registration on last page.
Has your name changed?
Yes
No
Has your mailing address changed?
Yes
No
Has the physical address changed?
Yes
No
Other Change(s):
Yes
No
If applicable, list all former names exactly as they appeared on your previous licenses.
DMV USE ONLY
Audit Line:
PID __________________
Print (270)
Name CHG
(231)
DOB CHG (231)
MISC CHG
(231)
POB SEX EYE HT WGT
Mail Address
(232)
SS# CHG (232)
Physical ADD (233)
ADD CHG DEL
Voter Reg
Create
220 260
222 225
228 227
234
DOC LOC
NNL Photo
VISA
USCIS Doc______
Eye Exam
Endorsements:
___ ___ ___
___ ___ ___
QSD
PDPS
QCS
OPR NEW 16
OPR RENEW 17
OOS LIC #
JUNIOR OPR 18
PERMIT NEW 19
Restrictions:
___ ___ ___
___ ___ ___
City & State (OOS)
PERMIT RENEW 20
EDL ($25.00) 33
Issue Date (VT)
EXAM, FIRST 21
EXAM, SUBSEQ 22
(Examiner – Authorized Agent)
RATER # DATE By:
Expire Date (VT)
TOTAL $
TA-VL-21 30M 06/2015 MTC Complete both pages or form will be returned! Page 1 of 2
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