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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 STATE BOARD OF ELECTIONS
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 NO YES NO
(INITIAL BOX) (INITIAL BOX) (INITIAL BOX) (INITIAL BOX)
INFORMATION FOR THE VIRGINIA TRANSPLANT COUNCIL

Yes, I would like to remain or become an organ, eye and tissue donor.
DRIVER'S LICENSE AND IDENTIFICATION CARD APPLICATION LOG #
Purpose: Use this form to apply for a Virginia Driver's License or Identification Card.
Instructions: Applicants complete the front and back of this application.
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)
1. Driver's License 2. Learner's Permit and Driver's License 3. CDL Learner's Permit or License 4. Motorcycle Learner's Permit
5. Driver's License with Motorcycle (Class M) 6. CDL with Motorcycle (Class M) 7. Driver's License with School Bus Endorsement
(to carry less than 16 passengers)
8. Identification Card 9. Hearing Impaired ID Card 10. Emancipated Minor ID Card 11. Driver's License Testing for Foreign Diplomats
If you are applying for a replacement license or identification card check one of the following:
I am surrendering my current license or identification card.
I hereby certify any current license or ID card is unavailable for surrender because it is Lost Stolen Destroyed or Mutilated
Do you currently have or have you ever held a driver's license or learner's permit from Virginia, another state, U.S. territory or foreign country? Yes No
If yes, provide the following:
LICENSE NUMBER ISSUE DATE (mm/dd/yyyy) EXPIRATION DATE (mm/dd/yyyy) STATE/COUNTRY
APPLICANT INFORMATION
NOTE: YOUR ADDRESS BELOW MUST BE CURRENT. THE U.S. POSTAL SERVICE WILL NOT FORWARD.
FULL LEGAL NAME (last, first, middle, suffix) SOCIAL SECURITY NUMBER BIRTHDATE (mm/dd/yyyy)
DAYTIME TELEPHONE NUMBER GENDER (check one) HEIGHT WEIGHT EYE COLOR HAIR COLOR
( ) MALE FEMALE FT. IN. LBS.
STREET ADDRESS APT NO. CITY STATE ZIP CODE
IF YOUR NAME HAS CHANGED, PRINT YOUR FORMER NAME HERE NAME OF CITY OR COUNTY OF RESIDENCE
CITY COUNTY OF
MAILING ADDRESS (if different from above) APT NO. CITY STATE ZIP CODE
DRIVER'S LICENSE APPLICANTS

YES NO 7. If you answered YES to any of
1. Do you wear glasses or contact lenses? these questions, please explain.
2. Do you have a physical or mental condition which requires that you take medication?
3. Have you ever had a seizure, blackout, or loss of consciousness?
4. Do you have a physical condition which requires you to use special equipment in order to drive?
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.)
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?
FOR DMV USE ONLY — DO NOT WRITE BELOW THIS LINE

REQUIRED TESTS PASSED FAILED REMARKS/PAID STAMP ENTER CUSTOMER NUMBER
VISION
DL ROAD SIGNS EXAM TRANSACTION TYPE FEE

ORIGINAL REISSUE
DL KNOWLEDGE EXAM
RENEWAL DUPLICATE
DL SKILLS
PROOF OF ID (primary) PROOF OF ID (secondary) PROOF OF SOCIAL SECURITY NUMBER (specify)
PROOF OF RESIDENCY (specify) PROOF OF LEGAL PRESENCE (specify)
CSR SIGNATURE AND NUMBER DOCUMENT VERIFIER SIGNATURE AND NUMBER

PARENT OR GUARDIAN CONSENT FOR APPLICANTS UNDER 18 (Unless applicant is married - marriage certificate required)
I authorize issuance of a learner's permit/driver's license/identification card. I certify that the applicant is a resident of Virginia. I certify that the applicant is
attending school regularly and is in good academic standing, but if not, I authorize issuance of a learner's permit/driver's license. I certify that this applicant will
operate a motor vehicle for at least 45 hours (15 of which will occur after sunset) while holding a learner's permit.
If my child attends public school, I authorize the principal or designee of the public school attended by the applicant to notify the juvenile and domestic relations
district court (within whose jurisdiction the applicant resides) when the applicant has had 10 or more unexcused absences from school on consecutive school
days.
I certify that the statements made and the information submitted by me regarding this certification are true and correct.
PARENT/GUARDIAN NAME (print) PARENT/GUARDIAN SIGNATURE DATE (mm/dd/yyyy)
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 NO
If you answered YES, a court within your jurisdiction 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:
JUDGE NAME (print) JUDGE SIGNATURE DATE (mm/dd/yyyy)
COMMERCIAL DRIVER'S LICENSE APPLICANTS

Complete this CERTIFICATION OF QUALIFICATION by checking the box for the category that applies. (For requirements refer to the Code of Federal
Regulations or VA Motor Carrier Safety Regulations).
INTERSTATE DRIVER INTRASTATE DRIVER
I meet the qualification requirements of Part 391 of the Federal Motor Carrier I meet the qualification requirements of the Virginia Motor Carrier
Safety Regulations. Safety Regulations.
I am exempt from the qualification requirements of Part 391 of the Federal Motor I am exempt from the qualification requirements of the Virginia
Carrier Safety Regulations. Motor Carrier Safety Regulations.
VEHICLE TYPE ENDORSEMENT Identify any state(s) in which you have been previously
I want to be licensed to operate the type of vehicle(s) checked below: licensed within the past 10 years. Provide additional
I want to apply for the following information using the Supplemental Driver's Licensing
A - Combination vehicle with GVWR or GCWR of 26,001 lbs. or more vehicle endorsement(s): History Sheet, form DL1PA.
B - Single vehicle with GVWR of 26,001 lbs. or more, or towing a H - Hazardous Materials STATE(S)
vehicle less than 10,000 lbs. GVWR. N - Tank
C - Any vehicle that does not fit the definition of a Class A or Class B
P - Passenger Carrying Vehicle LICENSE NUMBER
vehicle and is either used to transport hazardous materials or
(16 or more passengers)
designed to carry 16 or more passengers, including the driver.
S - School Bus LICENSE ISSUE DATE (mm/dd/yyyy)
(16 or more passengers)
AIR BRAKES T - Double/Triple Trailer LICENSE EXPIRATION DATE (mm/dd/yyyy)
With Without
GOVERNMENT EMPLOYEES - (Fee waiver certification)

I certify that I am employed by the:
Commonwealth of Virginia or City of County of Town of __________________________________________________________
to operate a motorcycle or commercial motor vehicle and, because of such employment, I am entitled to the waiver of the motorcycle class and/or commercial
motor vehicle endorsement fee, provided I have paid for and hold a valid Virginia driver's license or have made application for such.
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.
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.
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.
SIGNATURE (check one and sign) PARENT/GUARDIAN JUDGE, JUVENILE DOMESTIC RELATIONS COURT EMANCIPATED MINOR
CERTIFICATION AND SIGNATURES

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 knowingly making a false statement on this application is a criminal violation
APPLICANT NAME (print) APPLICANT SIGNATURE DATE (mm/dd/yyyy)

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Completion of this section is requested but not required to apply for a driver's license or ID Card. (Virginia Code §2.

INFORMATION FOR THE VIRGINIA TRANSPLANT COUNCIL

DRIVER'S LICENSE AND IDENTIFICATION CARD APPLICATION LOG #

DRIVER'S LICENSE APPLICANTS

FOR DMV USE ONLY — DO NOT WRITE BELOW THIS LINE

DL ROAD SIGNS EXAM TRANSACTION TYPE FEE

PROOF OF RESIDENCY (specify) PROOF OF LEGAL PRESENCE (specify)

CSR SIGNATURE AND NUMBER DOCUMENT VERIFIER SIGNATURE AND NUMBER

PARENT/GUARDIAN NAME (print) PARENT/GUARDIAN SIGNATURE DATE (mm/dd/yyyy)

JUDGE NAME (print) JUDGE SIGNATURE DATE (mm/dd/yyyy)

COMMERCIAL DRIVER'S LICENSE APPLICANTS

GOVERNMENT EMPLOYEES - (Fee waiver certification)

CERTIFICATION AND SIGNATURES

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