MV-44EDL (10/11) PAGE 1 OF 3 New York State Department of Motor Vehicles APPLICATION FOR ENHANCED DRIVER LICENSE OR NON-DRIVER ID CARD Batch File No. PLEASE PRINT CLEARLY IN BLUE OR BLACK INK. Image No. This form is also available on DMV’s web site at: www.dmv.ny.gov LRC LIS I AM APPLYING FOR AN ENHANCED (check any that apply): LAM LIN LRN LDP LNO POR PA M PRN PDP o Upgrade Current oLearner o ID o Renewal o Replacement oChange o NYS license in exchange for a license from another US card State, the District of Columbia or Canadian Province Document to EDL Permit VOTER REGISTRATION QUESTIONS (Please answer “yes” or “no”.) If you are not registered to vote where you live now, would you like to apply to register, or if you are changing your address, would you like the Board of Elections to be notified? NOTE: If you do not check either box, you will be considered to have decided not to register to vote. oYES - Complete Voter Registration Application Section oNO - I Decline to Register/Already Registered/I do not want to notify the Board of Elections of my change of address. NEW YORK STATE ORGAN AND TISSUE DONATION SIGN BELOW ♥ to enroll in the NYS Department of Health’s Donate Life SM Registry. By signing, you are certifying that you are: 18 years of age or older; consenting to donate all of your organs and tissues for transplantation, research or both; authorizing DMV to transfer your name and identifying information to DOH for enrollment in the Registry; and authorizing DOH to allow access to this information to federally regulated organ donation organizations and NYS-licensed tissue and eye banks and hospitals, upon your death. “ORGAN DONOR” will be printed on the front of your DMV photo document. You will receive a confirmation letter from DOH, which will also provide you an opportunity to limit your donation. o Check this box to make a $1 voluntary contribution to the Life...Pass It On Trust Fund. The $1 donation will be added to your total transaction fee. A contribution to the Fund is used for organ donation and transplant research and educational projects promoting organ and tissue donation. ♥Donor Consent Signature: ç ____________________________________________________ Date:_____________ IDENTIFICATION INFORMATION Do you now have, or did you ever have a New York: Driver license? . . . . . o Yes Learner permit? . . . . o Yes Non-driver ID Card? o Yes o No o No o No FULL LAST NAME } If “Yes”, enter the identification number as it appears on the license, learner permit, or non-driver ID card. ¦ NYS DRIVER LICENSE, LEARNER PERMIT, or NON-DRIVER ID CARD NUMBER Do you have or did you ever have a driver license that is valid or that expired within the past year, issued by another US State, the FULL FIRST NAME District of Columbia or a Canadian Province? o Yes o No If “Yes”, where was it issued? ____________________________ FULL MIDDLE NAME SUFFIX Date of Expiration: Type of License: DATE OF BIRTH Month Day SOCIAL SECURITY NUMBER* (SSN) SEX Year Male o EYE COLOR HEIGHT Female o Feet License ID No.: DAY PHONE NO. (Optional) Inches Area Code ( ) * You must provide your SSN. Authority to collect your SSN is granted by Sections 490.3 and 502 of the Vehicle and Traffic Law. The information will be used only for exchange with other jurisdictions, to assist in verification of identity, and to invoke driver license sanctions pursuant to V&T Law Section 510(4-e). Your number will not be given to the public, or appear on any form or information request. ADDRESS WHERE YOU GET YOUR MAIL - Include Street Number and Name, Rural Delivery and/or box number (If PO Box, also fill in “Address Where You Live” below) Apt. No. City or Town State Zip Code County ADDRESS WHERE YOU LIVE REQUIRED IF DIFFERENT FROM MAILING ADDRESS - DO NOT GIVE P.O. BOX. THIS ADDRESS WILL APPEAR ON YOUR DRIVER LICENSE. Apt. No. City or Town State Zip Code County Has your mailing address changed? Has your name changed? o Yes o No Has the address where you live changed? o Yes o No o Yes o No If “Yes”, print your former name exactly as it What is the change and the reason for it OTHER CHANGE: appears on your present license or non-driver ID card. (new license class, wrong date of birth, etc.)? PLEASE COMPLETE AND SIGN PAGE 2. F O R O F F I C E U S E Other Restrictions License Class A B C NCDL-C ID E M D DJ MJ Endorsements Special Conditions Vehicle Restrictions PP NF o Birth Certificate o Driver License/ID o MV-45 o Passport o Learner Permit o Residency o Credit Card o Image Retrieval o Social Security Card o Medical Certificate (CDL only) STOP/RESPONSE Proof Submitted: o Failed to answer summons o TEENS o Insurance lapse Other: o License/Permit Surrendered for Non-Driver ID Card AM ML DP UC LR UP Approved By Office LS UR BC X8 XT Date PAGE 2 OF 3 MV-44EDL (10/11) DRIVER LICENSE and LEARNER PERMIT APPLICANTS ONLY 1. Have you had, or are you being treated for, any of the following, or has a previous disability worsened? o Yes o No If “Yes”, check all that apply. o 1. Convulsive disorder, epilepsy, fainting or dizzy spells, or any condition which causes unconsciousness o 2. Heart ailment o 3. Hearing impairment o 4. Lost use of leg, arm, foot, hand, or eye o 5. Other (explain) ___________________________________________________________________________________________________________ If you checked box 1, you and your doctor must complete form MV-80U.1, “Physician’s Statement for Medical Review Unit”; if you checked box 2, your doctor must complete form MV-80, “Physician’s Statement”. These forms can be obtained at any Motor Vehicles office or at www.dmv.ny.gov. If you checked boxes 3, 4 or 5, you must contact a Motor Vehicles office for instructions. 2. Have you had a driver license, learner permit, or privilege to operate a motor vehicle suspended, revoked or cancelled, or an application for a license denied in this state or elsewhere, in this or any other name? o Yes o No If “Yes”, has your license, permit or privilege been restored, or your application approved? o Yes o No PARENT/GUARDIAN CONSENT o Junior License o Non-driver ID Card (under 16) I am the parent or guardian of the applicant, and I consent to the issuance of a learner permit, license or (if under 16) a non-driver ID card to him/her. I understand that I am responsible for certifying that the applicant has completed at least 50 hours of supervised “practice” driving, including 15 hours of driving after sunset, prior to the applicant taking a road test, and that this certification (MV-262) must be presented at the time of the road test. Note to parent/guardian: If the driver license applicant is 17 years old and has a Driver Education Student Certificate of Completion (MV-285), consent is not required. Parent or Guardian Sign Here ç (Relationship to Applicant) Teen Electronic Event Notification Service (TEENS) I would like to enroll in the TEENS program to be notified if the under 18 year-old applicant receives a conviction, suspension, revocation or an accident on their license file. For more information about this program, see form MV-1046, How to Enroll in TEENS or MV-1056, TEENS FAQs. This is a FREE service. (Date) NYS Client ID of Consenting Parent or Guardian Above- Required COMMERCIAL DRIVER LICENSE APPLICANTS ONLY Please answer questions 1 & 2, below: 1. Did you have a driver license from the District of Columbia or any US state, other than New York, in the past 10 years? If YES, list the names of all of the states or DC, but if you are turning in a license from another state, do not list that state: o Yes o No 2. Do you certify that you comply with federal requirements set forth in 49 CFR Part 391 and have a valid Medical Examiner’s Certificate? o Yes o No If YES, you must present your Medical Certificate to prove you meet this standard. If NO, will your commercial driving be limited to municipal and/or school operations only? o Yes o No NOTE: For an explanation of 49 CFR 391 requirements and operations that do not require a Medical Examiner’s Certificate, see form MV-44.5 Federal Requirements for Commercial Driver Applicants. CERTIFICATION I certify that the information I have given on this application is true. I certify that I am a citizen of the United States of America and a resident of New York State. If I am applying for a replacement license or non-driver identification card, I certify that the license or nondriver identification card has been lost, stolen or mutilated and that, if the lost license or non-driver identification card is found, I will turn it in to the Department of Motor Vehicles. If I am exchanging my out-of-state license for a NYS license, I certify that I was a permanent resident of the state or province in which my license was issued at the time the license was issued, that such license has been valid for at least 6 months, and that I have not failed a road test in NYS in the last 12 months. If I am a male at least 18 but less than 26 years old, I consent to be registered with the Selective Service System, if so required by federal law, and authorize the forwarding of any personal information required for such registration. My signature below also authorizes use of my credit card, if applicable. I understand that the information and documentation that I have provided in connection with this application will be used to verify my identity, New York State residency and United States citizenship. I understand that this information and documentation will be shared with the New York State and United States federal entities for these verification purposes and I consent to this dissemination and use. IMPORTANT: Making a false statement in any license or non-driver ID card application, or in any proof or statement in connection with it, or deceiving or substituting, or causing another person to deceive or substitute in connection with such application, is a misdemeanor under Section 392 of the Vehicle and Traffic Law, and may result in the revocation or suspension of your license or non-driver ID card. SIGN HERE ç PLEASE PRINT NAME ç CREDIT CARD AUTHORIZATION IF CARDHOLDER IS NOT THE APPLICANT: My signature authorizes____________________________________________ to use my credit card for payment of any fees in connection with this application and I understand that I must be present for this transaction. O F U F S I E C E Sign Here ç (Cardholder-Sign Name in Full) Applicant’s Signature TEST RESULTS Eye o Pass o Corrective Lens 1 Written o Pass o Fail 2 Examiner’s Initials PAGE 3 OF 3 NEW YORK STATE VOTER REGISTRATION APPLICATION INFORMATION MV-44EDL (10/11) OFFICE USE ONLY (Please read before you complete application on the other side.) You Can Use This Form To: l register to vote in New York State l change your name and/or address, if there is a change since you voted l enroll in a political party or change your enrollment To Register You Must: l be a U.S. citizen l be 18 years old by December 31 of the year in which you file this form (note: you must be 18 years old by the date of the general, primary or other election in which you want to vote.) l live in the county, city, or village, at least 30 days before an election l not be in jail or on parole for a felony conviction l not claim the right to vote elsewhere If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. If you believe that someone has interfered with your right to register or decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the NYS Board of Elections, 40 Steuben Street, Albany, NY 12207-2109, Phone 1-800-469-6872. If you have any questions about registering to vote, you should call your County Board of Elections or call 1-800-FOR-VOTE (only for Voter Registration questions). If you live in New York City, you should call 1-212-VOTE-NYC. Hearing impaired people with TDD may call 1-800-533-8683. You may also log on to our website for information at: www.elections.state.ny.us NEW YORK STATE VOTER REGISTRATION APPLICATION - (Fill out this part only if you want to register to vote or change your address or other information with the Board of Elections, and if you are also filling out the DMV application above.) If you register to vote, your completed voter registration application will be sent directly to the Board of Elections. If you decline to register, your decision will remain confidential. You will be notified by your County Board of Elections when your voter registration application has been processed. Are you a U.S. citizen? o Yes o No If you answered NO, do not complete this form. Last year voted I will be 18 years old on or before election day: Your Address was (give house number, street, and city) Choose a Party – Check one box only o o o o o o o o Please note: In order to vote in a primary election, you must be CONSERVATIVE PARTY enrolled in a party. WORKING FAMILIES PARTY *Except the Independence Party which permits nonINDEPENDENCE PARTY* enrolled voters to vote in GREEN PARTY their primary election. OTHER (write in) _______________________ DEMOCRATIC PARTY REPUBLICAN PARTY I DO NOT WISH TO ENROLL IN A PARTY MV-44EDL (10/11) o Yes o No Home Telephone Number (optional) If you answered NO, do not complete this form, unless you will be 18 by the end of the year. In county/state Area Code ( ) Under the name (if different from your name now) AFFIDAVIT: I swear or affirm that l I am a citizen of the United States. l I will have lived in the county, city, or village for at least 30 days before the election. l I meet all requirements to register to vote in New York State. l This is my signature or mark on the line below. l The above information is true. I understand that if it is not true I can be convicted and fined up to $5,000 and/or jailed for up to four years. ↓ Signature or mark X ↓ Date