NOTE: YOUR ADDRESS BELOW MUST BE CURRENT. THE U.S. POSTAL SERVICE WILL NOT FORWARD YOUR LICENSE OR ID CARD. PHONE NUMBER (optional) GENDER (check one) FEMALE MALE WEIGHT LBS. NAME OF CITY OR COUNTY OF RESIDENCE COUNTY OF CITY SOCIAL SECURITY NUMBER (SSN) 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 APPLICANT INFORMATION STREET ADDRESS APT NO. CITY STATE ZIP CODE HEIGHT FT. IN. MAILING ADDRESS (if different from above - this address will show on your license/permit/ID) APT NO. CITY STATE ZIP CODE SPECIAL INDICATOR REQUEST Please show the following indicator(s) on my license, permit, or ID card:Must submit required physician statement Insulin-dependent diabetic Speech impairment Hearing impairment (license only) Intellectual disability (IntD) Autism spectrum disorder (ASD) 1. Do you wear glasses or contact lenses to operate a motor vehicle? YES NO2. Do you have a physical or mental condition which requires that you take medication? If yes, please list the condition(s) and the name of the medication(s). YES NO3. Have you ever had a seizure, blackout, or loss of consciousness? YES NO4. Do you have a physical condition which requires you to use special equipment to drive? YES NO5. 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.) NO YES6. 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? NO YES If you answered YES to any of the above provide an explanation here. I HAVE NOT BEEN ISSUED A SSN. FOR DMV USE ONLY 227 DO NOT WRITE BELOW THIS LINE CUSTOMER NUMBER PROOF OF LEGAL PRESENCE (specify) TRANSACTION TYPE PROOF OF ID PROOF OF SOCIAL SECURITY (specify) PROOF OF RESIDENCY (primary) PROOF OF RESIDENCY (secondary) REQUIRED TESTS PASS FAIL VISION DL ROAD SIGNS EXAM DL KNOWLEDGE EXAM DL SKILLS MC KNOWLEDGE MC SKILLS M2 MC SKILLS M3 REMARKS/PAID STAMP RENEWAL DUPLICATE REISSUE ORIGINAL FEE Document Type Document Number Expiration Date (mm/dd/yyyy) Document Type Document Number Expiration Date (mm/dd/yyyy) DOCUMENT VERIFIER SIGNATURE AND LOGONID CSR SIGNATURE AND LOGONIDDRIVER'S LICENSE AND IDENTIFICATION CARD APPLICATIONDL 1P (10/01/2018) LOG # Driver's License Motorcycle Learner's Permit (classification not applicable) Identification (ID) Card Learner's Permit and Driver's License Driver's License with School Bus Endorsement (to carry less than 16 passengers) Hearing Impaired ID Card Driver's License with Motorcycle (complete Motorcycle Classification section below) Driver's License Testing for Foreign Diplomats Emancipated Minor ID Card Motorcycle Only License (complete Motorcycle Classification section below) Motorcycle Classification Maintaining current Virginia Motorcycle Classification Add, Upgrade or Transfer Motorcycle Classification or obtain Motorcycle Only License. Additional testing may be required. Check applicable box below. M 2 (2 wheels) M 3 (3 wheels) M (both 2 and 3 wheels) 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 2472.2-3806) INFORMATION FOR THE VIRGINIA TRANSPLANT COUNCIL Yes, I would like to become an organ, eye and tissue donor. YES (INITIAL BOX) NO (INITIAL BOX)Purpose: Use this form to apply for a driver's license, learner's permit, or identification card. Instructions: Submit completed application to any DMV Customer Center. Complete front and back of this application. Note: A $5 service fee applies to each license or identification card renewal conducted in a Customer Service Center (CSC) if the transaction is eligible to be performed by internet or mail, unless the renewal is conducted with another transaction that must be completed in person at a CSC. I certify I cannot surrender my current license or ID card because it is: I am surrendering my current license or ID card. Destroyed Stolen Lost Replacement License or Identification Card (check one of the following): APPLICATION TYPE Would you like your license/identification card to be REAL ID compliant? Yes No(Not applicable if applying for a Motorcycle Learner's Permit) American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION I certify and affirm that I am a resident of Virginia, that all information presented in this application is true and correct, that any documents I have presented to DMV are genuine, and that my appearance, for purpose of my DMV photograph, is a true and accurate representation of how I generally appear in public. I make this certification and affirmation under penalty of perjury and understand that making a false statement on this application is a criminal violation. By signing this form, I authorize DMV to verify the information provided on this application, as required to determine eligibility. DATE (mm/dd/yyyy) APPLICANT SIGNATURE APPLICANT NAME (print) GOVERNMENT EMPLOYEES - (Fee waiver certification) I certify that I am employed by the: to operate a motorcycle solely in the course of this employment and, because of such employment, I am entitled to the waiver of the motorcycle class endorsement fee, provided I have paid for and hold a valid Virginia driver's license or have made application for such. Town of County of City of Commonwealth of Virginia or Va. Code 24724746.2-323 and 46.2-342 require that you provide DMV with the information on this form (including your social security number). Your personally identifiable information is being collected for record keeping purposes and will be disseminated only in accordance with Va. Code 24724746.2-208, 46.2-209, and the Driver222s Privacy Protection Act, 18 USC 2472721. Persons convicted of certain sexual offenses (as listed in Va. Code 2479.1-902) must register or re-register with the Virginia Department of State Police as provided in Va. Code 2472479.1-901, 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 driver222s license or permit may be denied. Upon issuance of a driver222s license, commercial driver's license or identification card in the Commonwealth of Virginia, any driver222s license, commercial driver's license or identification card previously issued by another state must be surrendered and will be cancelled by the issuing state. NOTICE SIGNATURE (check one and sign) EMANCIPATED MINOR PARENT / GUARDIAN JUDGE, JUVENILE DOMESTIC RELATIONS COURT SELECTIVE SERVICE All males under the age of 26 are required to check one of the following. Failure to provide a response will result in denial of your application.By signing this application, I consent to be registered with Selective Service, if required by federal law. If under age 18, an appropriate adult must complete and sign below: I authorize DMV to send information to Selective Service which will be used to register applicant when he is 18 years old. I am already registered with Selective Service. I am a non-immigrant alien in the U.S. and not required to register. I authorize DMV to forward to the Selective Service System personal information necessary to register me with Selective Service. APPLICANT UNDER AGE 18 Have you ever been found not innocent of any offense in a Juvenile and Domestic Relations Court in this or any other state? YES NOIf you answered YES, the court making the adjudication of 223not innocent224 or a court within the jurisdiction where the juvenile222s parent/guardian resides must provide court consent below. COURT CONSENT In my opinion the applicant's request for a learner's permit/driver's license should be granted. should not be granted.REMARKS: PARENT/GUARDIAN NAME (print) PARENT/GUARDIAN SIGNATURE DATE (mm/dd/yyyy) DATE (mm/dd/yyyy) JUDGE SIGNATURE JUDGE NAME (print) Check applicable box, re