DL-14A - TEXAS DRIVER LICENSE OR IDENTIFICATION CARD APPLICATION FOR DEPARTMENT USE ONLY
(ADULT - 17 YEARS 10 MONTHS OF AGE AND OLDER) RESTRICTIONS/ENDORSEMENTS
NOTICE: All information on this application must be in INK. Applications held for 90 days only. DPS CANNOT REFUND PAYMENT ONCE APPLICATION IS SUBMITTED. ASSIGNED #
Application for: ✔ Driver License Identification Card Class (select one): A B ✔ C Motorcycle: Y ✔ N Select one: ✔ Original Renewal Replacement Address or Name Change APPLICANT INFORMATION Laura Last Name: Trevino Perez First Name: Middle Name: - -- Suffix: Birth Surname (Maiden): SSN:_ ____________________ - 15 - 1986 Date of Birth (mm/dd/yyyy): 07 Sex (select one): Male ✔ Female Height: Ft. In. Weight: Lbs. Eye Color (select one): Blue Brown Gray Hazel Green Black Maroon Pink Hair Color (select one): Black Red Gray Brown Blonde Bald White Race (select one): (AI) Alaskan or American Indian (AP) Asian or Pacific Islander (BK) Black (W) White Ethnicity (select one): (H) Hispanic Origin (O) Not of Hispanic Origin (U) Unknown Place of birth: City: State: County: Country: Father’s Last Name: Mother’s Maiden Name: CONTACT INFORMATION
Residence Address: City: State: Zip Code: County: Mailing Address: City: State: Zip Code: County: Home Phone: Other Phone: Email: In the event of injury or death would you like to provide up to two (2) emergency contacts? If yes, please list: a) Name Phone Number Address b) Name Phone Number Address Alternate Address: (Peace Officer or State / Federal Judge only) Address: City: State: Zip Code: County: REQUIRED INFORMATION FROM ALL APPLICANTS YES NO 1. Are you a citizen of the United States? If no, go to question 3. 2. If you are a U.S. citizen, would you like to register to vote? If registered, would you like to update your voter information? I understand that giving false information to procure a voter registration is perjury, and a crime under state and federal law. Conviction of this crime may result in imprisonment up to 180 days, a fine up to $2,000, or both. PLEASE READ ALL THREE STATEMENTS TO AFFIRM BEFORE SIGNING. I am a resident of the county provided above, and a U.S. citizen; I have not been finally convicted of a felony, or if a felon, I have completed all of my punishment including any term of incarceration, parole, supervision, period of probation, or I have been pardoned; And I have not been determined by a final judgment of a court exercising probate jurisdiction to be totally mentally incapacitated or partially mentally incapacitated without the right to vote. By providing my electronic signature, I understand the personal information on my application form and my electronic signature will be used for submitting my voter’s registration application to the Texas Secretary of State’s office. Wanting to register to vote, I authorize the Department of Public Safety to transfer this information to the Texas Secretary of State. 3. Are you a veteran? If no, go to question 4. a.) Are you a 60% disabled Veteran receiving compensation and want to waive the application fee? (Proof of disability required) b.) Do you want a Veteran designator on your DL or ID, or c.) Are you 50% disabled or are you 40% and have had a lower extremity amputated and want a Disabled Veteran designator on your DL or ID? (Proof of honorable discharge required; some acceptable documents are DD214/215, NGB22, VA disability letter, Veteran Identification card, proof of service/ verification of honorable service card. Proof of disability is required for Disabled Veteran designator) d.) If you want a Veteran or Disabled Veteran designator, do you want the branch of service shown on your DL or ID? If yes, select one: Army Air Force Coast Guard Marines Navy 4. Do you have a health condition that may impede communication with a peace officer? (Physician must complete form DL-101). 5. Would you like to register as an organ donor? 6. Do you want to donate $1.00 to the Blindness Education Screening and Treatment Program? 7. Do you want to support the Glenda Dawson Donate Life Texas donor registry? If yes, please indicate a donation amount of $1 or more $ .00. 8. Do you want to support Texas Veterans? If yes, please indicate a donation amount of $1 or more $ .00. 9. Do you want to support survivors of sexual assault? If yes, please indicate a donation amount of $1 or more $ .00 to help fund the testing of sexual assault evidence collection kits (rape kits). 10. Do you want to support the issuance of a DL/ID for foster or homeless youth? If yes, please indicate a donation amount of $1 or more $ .00 to exempt this population from paying any fees.
DL-14A (Rev. 7/2020) APPLICATION CONTINUED ON BACK
REQUIRED INFORMATION FROM DRIVER LICENSE APPLICANTS ONLY (FOR CONFIDENTIAL USE OF THE DEPARTMENT ONLY) MEDICAL HISTORY QUESTIONS YES NO 1. Do you currently have or have you ever been diagnosed with or treated for any medical condition that may affect your ability to safely operate a motor vehicle? Examples, including but not limited to: Diagnosis or treatment for heart trouble, stroke, hemorrhage or clots, high blood pressure, emphysema (within the past two years) • progressive eye disorder or injury (i.e., glaucoma, macular degeneration, etc.) • loss of normal use of hand, arm, foot or leg • blackouts, seizures, loss of consciousness or body control (within the past two years) • difficulty turning head from side to side • loss of muscular control • stiff joints or neck • inadequate hand/eye coordination • medical condition that affects your judgment • dizziness or balance problems • missing limbs Please explain and identify your medical condition: 2. Do you have a mental condition that may affect your ability to safely operate a motor vehicle? If yes, how? Please explain:
3. Have you ever had an epileptic seizure, convulsion, loss of consciousness, or other seizure? 4. Do you have diabetes requiring treatment by insulin? 5. Do you have any alcohol or drug dependencies that may affect your ability to safely operate a motor vehicle or have you had any episodes of alcohol or drug abuse within the past two years? 6. Within the past two years have you been treated for any other serious medical conditions? Please explain:
7. Have you EVER been referred to the Texas Medical Advisory Board for Driver Licensing?
REQUIRED INFORMATION FROM FIRST TIME DRIVER LICENSE APPLICANTS ONLY
DRIVER HISTORY INFORMATION YES NO 1. Have you ever had a driver license, identification card or instruction permit in Texas or any other state? List state(s): Number(s): When? 2. Are you enrolled in or have you completed an approved driver education course? 3. Is your driver license or driver privilege CURRENTLY or EVER been suspended, revoked, cancelled, denied or disqualified in ANY state? State? When? Why? VEHICLE REGISTRATION AND INSURANCE INFORMATION 1. Do you own a motor vehicle that is required to be registered? (Texas Transportation Code section 502.040) 2. Do you own a motor vehicle that is required to have liability insurance OR other proof of financial responsibility in compliance with the Motor Vehicle Safety Responsibility Act? (Texas Transportation Code section 601.051)
NOTICE: The information on this application is required by the Texas Driver License Act, Texas Transportation Code Chapter 521. Failure to provide the information is cause for refusal to issue a driver license or identification card, and in some cases, cancellation or withdrawal of driving privileges. False information could also lead to criminal charges with penalties of a fine up to $4,000.00 and/or jail.
SOCIAL SECURITY NUMBER COLLECTION DISCLOSURE
Disclosure of your social security account number is mandatory for identification card and driver license applicants, but voluntary for election identification certificate applicants. This information is solicited pursuant to 42 U.S.C. section 405(c)(2)(C)(i), 42 U.S.C. section 666(a)(13)(A), 6 C.F.R. section 37.11(e), 49 C.F.R. section 383.153, Texas Family Code section 231.302(c)(1), and Texas Transportation Code sections 521.142 and 522.021. The Department will use social security number information for identification purposes and will only release the number as statutorily authorized by Texas Transportation Code section 521.044.
UNITED STATES SELECTIVE SERVICE
Any male at least 18 but younger than 26 years of age submitting this application consents to registration with the United States Selective Service System. Alternative options for those who object to conventional military service for religious or other conscientious reasons may be found at: https://www.sss.gov/About/Alternative-Service. By submitting this application, I am consenting to registration with the United States Selective Service System if my registration is required by federal law.
DO NOT SIGN BELOW UNTIL INSTRUCTED TO DO SO BY NOTARY PUBLIC OR DRIVER LICENSE EMPLOYEE. CERTIFICATION I do solemnly swear, affirm, or certify that I am the person named herein and that the statements on this application are true and correct. I further certify my residence address is a (select one): single family dwelling, apartment, motel, temporary shelter. I agree to immediately report to the Texas Department of Public Safety any changes in my medical condition which may affect my ability to safely operate a motor vehicle. I further understand that I am required by law to report any change of name or address to the Department of Public Safety within thirty days.
X Signature of Applicant Date
Sworn to and subscribed before me this day of ,
Notary Public in and for the State of Texas/Authorized Officer
✔ Has passed Class C-Road Rules and Class C-Road Signs examinations : Grade: Road Rules ____ P Road Signs ____ P ✔ Must take vision exam with the Department of Public Safety
Name: _________________________,_____________________________ Trevino Perez Laura 07/15/1986 // Date of Birth:___________ Male ✔ Female Last First I hereby certify that the person indicated has completed and passed a 6-hour driver education course exclusively for adults approved by TDLR.
_______________________________ 0857 ___________ Virtual Drive Management, LLC _____________________________ Signature of Licensed Driver Education Instructor TDLR Number Name of School
____________________________________________ C-2636 __________________________________ _____________________________ 01/26/2024 Signature or Signature Stamp of ChiefSchool Official Driver Education School Number Date Issued
CUSTOMER SERVICE PHONE NUMBER: 806-352-9558
WARNING: You may commit a crime if you give this driver education certificate to the Department of Public Safety and you did not complete the course or if you put any information on this certificate that is not true. If you have reason to believe that the minimum requirements are not being met by this driving school, contact TDLR: PO BOX 12157 • Austin TX 78711 • (512) 463-6599
UNLAWFUL IF REP.RODUCED OR ALTERED - INVALID IF VIR TUAL DRIVE SEAL IS NOT. VISIBLE ADE-1317
