APPLICATION FOR DRIVING PRIVILEGES OR ID CARD

 ORIGINAL 
RENEWAL 
DUPLICATE 
ADDRESS CHANGE 
INSTRUCTION PERMIT 
CHANGE
Information in boxes MUST be completed prior to visiting a DMV representative. Please PRINT in black or blue ink only.
LICENSE OR PERMIT CLASSIFICATION ENDORSEMENTS IDENTIFICATION CARD
 Real ID  Standard  Class C
✔  Class A J  F  Real ID  Standard
✔ Driver Authorization Card
  Class M  Class B  Seasonal Resident
LAST NAME (PRINT) FIRST NAME MIDDLE NAME SUFFIX NEVADA DL/DAC/ID NUMBER
QUIALA BONGO ANTONIO
SOCIAL SECURITY NUMBER (Except DAC) DATE OF BIRTH FULL LEGAL NAME ON BIRTH CERTIFICATE BIRTHPLACE (STATE AND COUNTRY)
01/02/1981 ANTONIO QUIALA BONGO LUANDA , ANGOLA
SEX (CIRCLE 1) HEIGHT WEIGHT HAIR COLOR EYE COLOR MOTHER’S MAIDEN NAME
M ● F X FT. IN. LBS.
Do not scan my Birth Certificate  YES, print my mailing address on the front of my card (Except Real ID)
PRIMARY PHYSICAL ADDRESS (PRINCIPAL RESIDENCE) MAILING ADDRESS (IF DIFFERENT FROM PHYSICAL ADDRESS)
2580 N Buffalo Dr , APT 1203A
CITY, STATE, ZIP CODE CITY, STATE, ZIP CODE
Las Vegas , NV , 89128
DAYTIME PHONE NUMBER (OPTIONAL) EMAIL ADDRESS (OPTIONAL)
( )
CITIZEN Are you a United States citizen?  YES  NO
Are you 18 years or older?  YES  NO
Are you currently 17 and would like to preregister? You will be able to vote when you turn 18.  YES  NO
If you are eligible, you will be registered to vote or have your voter registration updated. If you want to choose a
political party or opt-out of registering to vote, we will give you a form at the end of your transaction today. Unless you opt-
out, we will send your information to your County Clerk/Registrar. If you had a felony conviction, you are eligible to vote on
VOTER release from prison. Your choice to register to vote or not and the place where you register are confidential and will not affect
REGISTRATION the assistance or services provided to you by the DMV. Nevada Revised Statute Chapter 293.
Uniformed and Overseas Citizens Absentee Voting Act (UOCAVA). If applicable, check one of the following:
 Domestic Military (or military spouse or dependent) on active duty and absent from Nevada voting residence
 Overseas Military (or military spouse or dependent) on active duty and absent from Nevada voting residence
 Overseas Citizen residing outside the U.S. (not applicable to those traveling/vacationing outside the U.S.)
ORGAN Would you like to be an organ donor and have that indicated on your license or identification card?  YES  NO
DONOR If you would you like to donate $1 or more to the anatomical gift account, indicate how much here: $______________
Have you ever had a driver’s license or identification card in another name?  YES  NO
If yes, under what name was it issued?
Have you ever had a driver’s license or identification card in another state?  YES  NO
DRIVING If yes, list all states you have ever had a driver’s license or identification card: _____________________
HISTORY License #: Class/Type: Expiration Date:
Has your driving privilege ever been revoked, suspended, canceled or denied?  YES  NO
If yes, from which state(s): Date: Reason:
Do you have a disability or missing extremity?  YES  NO
MEDICAL Do you have any illness or take any medication that could affect your driving ability?  YES  NO
HISTORY If you answered YES to either question, please explain:  YES  NO
NOTE: Some medical conditions may be indicated on your DL/DAC/ID. Form DLD7 must be completed by a physician.

OFFICE USE ONLY Individual ID #: Drive Written:

Vision Acuity Correction Reinstatement Info: ___________________________

With OR Without Restrictions: _________________________________

PDPS/CDLIS: CLEAR HIT W/D:________________ CITES: _________ 2 nd HIT
LEFT BOTH RIGHT
20/___ 20/___ 20/___
State:________________ DLN:____________________
Docs/Notes: ___________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

 TURN OVER 

DMV-002E Revised 6/2021

SELECTIVE
If you were born male and are 18-26 yrs old, you will be registered for Selective Service. If you are  NO, I am not
eligible but choose NO, you will no longer be eligible for federal student loans, grants, benefits relating eligible or do not
SERVICE wish to register
to job training, most federal jobs and, if applicable, U.S citizenship.
I have a U.S. Armed Forces honorable discharge and wish to have a veteran designation placed/retained  YES  NO
1 on my license. If your card does not already have a veteran designation, you must present proof of
honorable discharge.

2 Have you ever served on active duty in the Armed Forces of the United States and separated from such
 YES  NO
service under conditions other than dishonorable?
VETERAN
Have you ever been assigned to duty for a minimum of 6 continuous years in the National Guard or a  YES  NO
3 reserve component of the Armed Forces of the United States and separated from such service under
conditions other than dishonorable?
Have you ever served the Commissioned Corps of the United States Public Health Service or the  YES  NO
Commissioned Corps of the National Oceanic and Atmospheric Administration of the United States in the
4
capacity of a commissioned officer while on active duty in defense of the United States and separated
from such service under conditions other than dishonorable?

STOP
You will fill this out with the DMV Representative so they can witness your signature
CONSENT FOR MINOR’S LICENSE: I consent to the issuance of an instruction permit/license to , whose
relationship to me is . I understand I can be held responsible for any liability caused by his/her
negligence or willful misconduct in the operation of a motor vehicle (NRS 483.300 and/or NRS 486.101). I understand I may have the
permit/license cancelled & be released from liability by signing a cancellation request. I understand, before a license is issued, he/she may
need to present a DMV-301 Certification of Attendance, a Certificate of Completion from a Nevada DMV-approved Driver Education
Course, & a DLD-130 Beginning Driver Experience Log attesting he/she has completed at least 50 hours of behind-the-wheel driving
experience.
Initial _____________

INSTRUCTION PERMIT: I certify that I understand my instruction permit is valid for up to one (1) year from date of Initial
issuance and I must carry it with me when I am driving. I understand the restrictions of my permit and agree to
follow them.

MINOR ORGAN DONOR: I, parent/guardian of minor applicant, understand unless the anatomical gift is amended Parent/Guardian Signature
or revoked by the donor before his/her death, I may not amend or revoke the anatomical gift.

NON-USE OF NEVADA DRIVING PRIVILEGE: I have not operated a motor vehicle since: _______Date Initial

NO SOCIAL SECURITY NUMBER: I certify I have never been assigned a Social Security Number under the Initial
provisions of the Social Security Act of the United States.

DISCLOSURE STATEMENTS:
*The Privacy Act of 1974 is a federal law authorizing the use of your Social Security Number to verify identity. You are
required to submit your Social Security Number so the state may administer laws related to licensing drivers (NRS 483.290).
The driver’s license or identification card application you are submitting will cause any driving record from your previous state
to be transferred to Nevada and will show as surrendered. NRS 482.385 requires you to register each vehicle you own and
operate within 30 days of becoming a resident.
I hereby certify, under penalty of perjury, that all statements in this application are true and correct. I understand that any and all
other driver’s licenses or identification cards issued by any other jurisdiction will be surrendered upon issuance of a Nevada
license or identification card. I agree and understand that any misstatement of material facts may cause cancellation and/or
denial of my license or identification card under NRS 483.420 and NRS 483.530, respectively. I further understand that any
misstatement of facts may be a misdemeanor or felony under NRS 483.530 and may be punishable pursuant to NRS 193.130.

Applicant Signature _______________________________________________________________Date_________________________

Parent/Guardian Signature if Applicant is under 18 ______________________________________ DL/ID_______________________

Sworn before me this ___________________ Day of ___________________________________________20____________________

Authorized DMV Representative/Notary Public ______________________________________________________________________

Signatures must be originals. Photocopies are not acceptable. Changes may not be made to this form once signed.

DMV-002E Revised 6/2021