Diver License/ Identification Card Application - Arizona

DRIVER LICENSE / IDENTIFICATION CARD APPLICATION

Type:  Driver License  Motorcycle  Instruction Permit  Identification Card

You are required by A.R.S. §§ 28-3158(D)(5) and §§ 28-3165(F), under authority of 42 U.S.C. §§

405(c)(2)(C) and

666 (a)(13)(A), to provide your Social Security Number. It will be used to verify your

identity and to comply with federal and state child support enforcement laws. It will not be used as your

driver license or identification card number.

Social Security Number

Applicant Name (first, middle, last, suffix)

−

Residence Street Address (Unit # / Apt #)

City

State

Zip

Mailing Address (if different from above) (Unit # / Apt #)

City

State

Zip

 Street  Mailing Which address do you want to appear on your license?

Sex

 Male  Female

Weight

Height

Eye Color

Hair

Date of Birth

Current Driver License Number

Name on Current Driver License or ID (if different from above)

Class

 Operator  Motorcycle  Commercial (CDL)  Identification Card

State

Issue Date

Expiration Date



Yes



No Has your driving privilege ever been suspended, disqualified, canceled, denied or revoked?

If Yes:

States

Dates

Reasons

 Yes  No Is your driving privilege now suspended, disqualified, canceled, denied or revoked?



Yes



No Do you have a license from more than one state or jurisdiction?

 My vehicle is registered in another state (indicate which state):

State



I am active duty military or family member.

 I am an out-of-state student or family member.

 I want to show a medical alert condition on my license/ID (must submit physician or registered nurse practitioner statement).



I also want this alert maintained on my permanent computer record. (If not checked, when you reapply or request a duplicate, the alert will not

appear on your license/ID unless you resubmit a physician or registered nurse practitioner statement.)

 I consent to the release of personal information contained in my driver license and vehicle record. I understand that this is not a one-time consent that

applies only to a specific individual or organization, but is instead a general consent that applies to all requests from any and all individuals or

organizations for any purpose, until revoked by me in writing. Consent for a vehicle record applies to all owners.

 Yes  No Do you have a physical, psychological or visual condition (other than wearing glasses or contact lenses) or alcohol/drug dependency or are

you taking any medications that could affect your ability to safely operate a motor vehicle? (driver license applicants only)

Please Explain

 Yes  No Have you ever been determined to be incapacitated by a court? (driver license applicants only)

 Yes  No Are you a United States citizen who wishes to register to vote or update your existing voter registration?

 I want to be placed on the permanent early voting list and receive an early ballot by mail for each election I am eligible.

Party Preference

 DONOR♥ I check this box to become an organ/tissue donor and join the DonateLifeAZ Registry. DONOR♥ will print on my license.

 I am a U.S. Military veteran and would like the word “VETERAN” printed on my license/ID. (Documentation Required)

All Applicants: I certify that the information above is true and correct. I understand that I must report a change of address or name to MVD within 10

days. All Driver Applicants: I understand the laws, rules and regulations described in the Arizona Driver License Manual, and that I must report to

MVD in writing, within 10 days, any medical condition that develops or worsens that may affect my ability to safely operate a motor vehicle.

Male Applicants Under 26: By submitting this application, I consent to registration with the Selective Service System if I am required to register

under federal law. If I am under 18, I understand that I will be registered as required by federal law when I become 18.

Voter Registration: I certify that I am not a convicted felon or my civil rights have been restored, and that I have not been adjudicated incompetent. I

certify that I am a United States citizen. Submitting a false voter registration is a Class 6 felony. Your decision to register to vote or not, and where

you submitted your application, will remain confidential.

Applicant Signature (If under 18, Legal Guardian Certificate on the back must be completed.)

Acknowledged before me

this date.

Notary or MVD Agent Signature

Date

County

State

Commission Expires

40-5122 R10/14 azdot.gov

Clear

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