Driver's License and Identification Card Application - 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