Driving Licence Application Form - Texas

REQUIRED INFORMATION FROM ALL APPLICANTS

YES NO

1. Are you a citizen of the United States?

2. If you are a US citizen, would you like to register to vote? If registered, would you like to update your voter information?

By providing my electronic signature, I understand the personal information on my application form and my electronic signature will be used for

submitting my voter’s registration application to the Texas Secretary of State’s office. Wanting to register to vote, I authorize the Department of

Public Safety to transfer this information to the Texas Secretary of State.

3. Do you wish to donate $1.00 to the Blindness Education Screening and Treatment Program?

4. Do you wish to donate $1.00 to the Glenda Dawson Donate Life – Texas Registry?

5. Would you like to register as an organ donor?

6. Do you want to support Texas Veterans? If yes, please indicate your donation amount $ .00

7. Do you have a health condition that may impede communication with a peace officer? If yes, please list

(physician must complete form DL-101 prior to the issuance of a DL/ID).

8. a) Do you want a Veteran designator on your driver license or identification card? (proof of Honorable discharge required; acceptable documents

are DD214/5, NGB22, VA disability letter, proof of service/verification of honorable service card)

b) Are you a 60% disabled Veteran receiving compensation and want to waive the application fee? (see 8a for documents required)

9. In the event of injury or death would you like to provide two (2) emergency contacts? If yes, please list:

a) Name Telephone Number Address

b) Name Telephone Number Address

10. Have you ever had a Texas identification card? Number When?

11. Have you ever had a driver license or instruction permit in Texas? Number When?

12. Have you ever had a license or instruction permit in any other state? List state(s)

Number(s) When?

REQUIRED INFORMATION FROM DRIVER LICENSE APPLICANTS

YES NO DRIVING HISTORY INFORMATION

13. Are you enrolled in or have you completed an approved driver education course?

14. Is your driver license or driver privilege CURRENTLY or EVER been suspended, revoked, canceled, denied or disqualified in ANY state?

Where? When? Why?

VEHICLE REGISTRATION AND INSURANCE INFORMATION

15. Do you own a motor vehicle which is required to be registered (Texas Transportation Code Section 502.040)?

16. Do you own a motor vehicle which is required to have liability insurance OR other proof of financial responsibility in compliance with the

Motor Vehicle Safety Responsibility Act (Texas Transportation Code Section 601.051)?

UNITED STATES SELECTIVE SERVICE

Any male United States citizen or immigrant who is at least 18 years of age but less than 26 years of age submitting this application consents to registration with the United

States Selective Service System. You must be registered to qualify for federal student aid ( to include Pell grant), job training, federal employment, and citizenship if an

immigrant. In Texas, you must be registered to qualify for state college student aid or state employment. If convicted, failure to register with the Selective Service is a

felony punishable by up to five years in prison and/or a $250,000 fine. If not registered by age 26, you can no longer register and could permanently lose those benefits

associated with registration. For alternative options for applicants who object to conventional military service for religious or other conscientious reasons information is

available at: http://www.sss.gov/FactSheets/FSaltsvc.pdf

DL-14A (Rev. 6/14) APPLICATION CONTINUED ON BACK

APPLICATION for: DRIVER LICENSE COMMERCIAL DRIVER LICENSE (CDL) LEARNER LICENSE

IDENTIFICATION CARD NON-RESIDENT COMMERCIAL DRIVER LICENSE Class (Circle) A BCM

APPLICANT INFORMATION

LAST NAME:

FIRST NAME:

MIDDLE NAME:

SUFFIX:

MAIDEN NAME:

DATE OF BIRTH (mm/dd/yyyy): — —

SSN: — —