ID Card Application Form - 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)
Document Type Document Number Expiration Date (mm/dd/yyyy)
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)
NO
(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)
NO
(INITIAL BOX)
LOG #
1. Driver's License
2.
Learner's Permit and Driver's License
3.
Motorcycle Learner's Permit (classification not applicable)
4.
Driver's License with School Bus Endorsement
(to carry less than 16 passengers)
5.
Driver's License Testing for Foreign Diplomats
6.
Commercial Learner's Permit or License
7.
Identification (ID) Card
8.
Hearing Impaired ID Card
9.
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
5. Have you been convicted within the past ten years in this state or elsewhere of any offense
resulting from your operation of, or involving, a motor vehicle? (Do not include parking tickets.)
NOYES
6. Has your license or privilege to drive ever been suspended, revoked, or disqualified in this state
or elsewhere, or is it currently suspended, revoked or disqualified?
NOYES
SPECIAL INDICATOR REQUEST
Please show the following indicator(s) on my license
or ID card:
Insulin-dependent diabetic
Autism spectrum disorder (ASD)
Intellectual disability (IntD)
Hearing impairment (license only)
Speech impairment
Must submit required physician statement
If you answered YES to any of the above provide an explanation here.
REQUIRED TESTS
PASS FAIL
VISION
DL ROAD SIGNS EXAM
DL KNOWLEDGE EXAM
DL SKILLS
MOTORCYCLE KNOWLEDGE
MOTORCYCLE SKILLS M2
MOTORCYCLE SKILLS M3
RENEWALDUPLICATEREISSUEORIGINAL
FEE
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ID Card Application Form - Virginia PDF

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