APPLICATION FOR PERMIT, DRIVER LICENSE OR NON-DRIVER ID CARD PAGE 1 OF 3
PRINT CLEARLY IN BLUE OR BLACK INK. OFFICE USE ONLY This form is also available at dmv.ny.gov Image # APPLYING FOR: PURPOSE FOR APPLICATION:
• License • ✔Permit • ID card ✔New • Renew • Update Info •Change Type •Replacement • Conditional • Restricted • Transfer • New York to
IDENTIFICATION INFORMATION ID NUMBER ON NEW YORK STATE DRIVER LICENSE,
Do you now have, or did you ever have a New York LEARNER PERMIT, or NON-DRIVER ID CARD driver license, learner permit, or non-driver ID card? • Yes • ✔No • •
Applying for a Non-Driver ID card will cancel any New York State driver license privilege.
FULL LAST NAME Do you have or did you ever have a driver license that is valid or that Antrim expired within the last two years, issued by another U.S. State, the District of Columbia or a Canadian Province? • Yes • ✔No• •
FULL FIRST NAME
Noah If “Yes”, where was it issued? FULL MIDDLE NAME Date of Expiration: Type of License: Out-of-State License ID No.: August SUFFIX DATE OF BIRTH SEX HEIGHT EYE COLOR TELEPHONE NUMBER (Home/Mobile) Month Day Year • • M F X • Feet Inches Area Code • • 12 27 0 7 • •✔•••• 5 9 Brown ( 914 ) 4517748 Has your name changed? • Yes • • ✔No If “Yes”, print your former name exactly as it appears on your present license or non-driver ID card. •
OTHER CHANGE: What is the change and the reason
for it (new license class, wrong date of birth, etc.)? SOCIAL SECURITY NUMBER* (SSN) * If you were ever issued an SSN, you must provide the number. Authority to collect your SSN is granted by Sections 490(3) and 502(1) of the Vehicle and Traffic Law. The information will be used for exchange with other jurisdictions, to assist in verification of identity, and for driver license sanctions If you have never been issued a Social Security Number, check this box • • pursuant to V&T Law Section 510(4-e) and 510(4-f). Your SSN will not be given to the public.
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) THIS ADDRESS WILL APPEAR ON YOUR STANDARD IDENTITY DOCUMENT Apt. No. City or Town State Zip Code County 116 library lane #2 Mamaroneck NY 10543 WESTCHESTER ADDRESS WHERE YOU LIVE REQUIRED IF DIFFERENT FROM ADDRESS FOR MAIL - DO NOT GIVE P.O. BOX. THIS ADDRESS WILL APPEAR ON YOUR ENHANCED/REAL ID IDENTITY DOCUMENT Apt. No. City or Town State Zip Code County
HAS YOUR MAILING ADDRESS CHANGED? • Yes •
✔ No • • HAS THE ADDRESS WHERE YOU LIVE CHANGED? • Yes • • ✔ No •
If you answered yes to either of the questions above, then addresses on all vehicle registrations tied to your ID number will also be updated with this address, unless you check this box • . If you are registered to vote, your voter registration record will be updated when you complete and submit this form. If you do NOT want your new address on your •
voter registration record, check this box •. If you do not check the box, your new address will be sent to the Board of Elections of your county of residence. •
••••••• Check this box if you would like to have “Veteran” printed on the front of your photo document. VETERAN STATUS • • You must present proof that indicates an honorable discharge from military service (ex: DD-214, DD-215).
VOTER REGISTRATION If you are not registered to vote where •••••••
• YES - Complete Voter Registration Application Section NOTE: If you do not check either box, QUESTIONS you live now, would you like to apply to (Not necessary if you bring this form to a DMV office). you will be considered to have decided (Please check ‘Yes’ or ‘No’.) register? • ✔NO - I Decline to Register/Already Registered not to register to vote.
REGISTRATION WITH THE UNITED STATES SELECTIVE SERVICE SYSTEM (SSS)
All male U.S. citizens and immigrants ages 18 through 25 must register with SSS or violate the law. Failure to register is a felony punishable by up to five years in prison and/or a $250,000 fine. If not registered by age 26, you can no longer register and will permanently lose benefits associated with registration, and you will be disqualified from access to: U.S. citizenship if an immigrant; Pell Grants and federal student aid; job training programs; and all federal and postal jobs and many state employment jobs. Should you elect not to register you may do so by checking the “No” box and the pre-mentioned benefits will be lost. • NO PLEASE COMPLETE AND SIGN PAGE 2. OFFICE USE ONLY
• TEENS• License Special CDL Certifications NI NA EI EA Class Conditions Approved By Date Office Other Restrictions THESE QUESTIONS MUST BE COMPLETED FOR ALL LICENSE/PERMIT TRANSACTIONS 1. Has your driver license, learner permit, or privilege to drive a motor vehicle 3. Do you need a hearing aid and/or full view mirror to drive a motor vehicle? been suspended, revoked or cancelled, or has your application for a license been denied in this state or elsewhere, in the name you provide on this form ••Yes • ✔No or any other name? 4. Have you lost the use of a leg, arm, hand or eye? • •Yes •✔No ••Yes • ✔No If “Yes”, has your license, permit or privilege been restored, or has your 4a. If you need to renew your driver license and you marked “Yes”, did this application been approved? occur since your last driver license? • •Yes • No ••Yes • No 2. Have you received treatment, do you currently receive treatment, or do you 4b. If you marked “NO” to 4a, has your condition gotten worse since your take medication for any condition that causes unconsciousness or last driver license? ••Yes • No unawareness (for example, a convulsive disorder, epilepsy, fainting or dizziness, or a heart condition)? ••Yes • ✔ No If you marked “Yes”, you must submit form MV-80U.1, even if you were released from the Medical Review Program. You can get this form at any Motor Vehicles office or at dmv.ny.gov
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. 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 (form 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 (form MV-285), consent is not required.
Parent or Guardian Sign Here X (Relationship to Applicant) (Date) Teen Electronic Event Notification Service (TEENS) ID Number on New York State Driver License, Permit or I would like to enroll in the TEENS program to be notified if the under 18 year-old applicant Non-driver ID Card of Consenting Parent or Guardian receives a conviction, suspension, revocation or an accident on their license file. For more Above (Required) information about this program, see form MV-1046, How to Enroll in TEENS or MV-1056, TEENS FAQs. This is a FREE service.
COMMERCIAL DRIVER LICENSE APPLICANTS ONLY
1. In the past 10 years, was a driver license issued to you from another state in the U.S. or the District of Columbia ? • Yes • • • No If YES, write the name of each one 2. Are you subject to any disqualification under section 383.51, title 49 of Code of Federal Regulations or NYS Law? • Yes • • No •
3. You MUST certify to DMV that you operate (or expect to operate) a commercial motor vehicle in one of the following four driving types (select only one):
• Non-excepted Interstate (NI) - Certified medical status is required. You • Excepted Interstate (EI) -You are age 18 or older and you operate, or are age 21 or older and you operate, or expect to operate, interstate expect to operate, interstate in Excepted Operation ONLY. You must (other than for excepted operation). have A3 restriction. • Non-excepted Intrastate (NA) - Certified medical status is required. You • Excepted Intrastate (EA) - You are age 18 or older and you operate, or are age 18 or older and you operate, or expect to operate, in New expect to operate, in Excepted Operation ONLY and in New York State York State only (other than for excepted operation). ONLY. You must have A3 and K restrictions. If the driving type you selected requires certified medical status (NI or NA) you must provide a legible copy of your current USDOT Medical Examiner’s Certificate to DMV if it is not already on file. Please see DMV form MV-44.5 if additional information is needed to help you determine your driving type.
CERTIFICATION I certify that the information I have given on this application and on any documentation provided in support of this application is true and complete. I understand that making a false statement on this application, or submitting any documentation in support of this application that is false, may be punishable as a criminal offense. If I am applying for a replacement document, I certify that my New York State document has been lost, stolen, or mutilated. If I am transferring an Out-of-State Driver License to a New York State Driver License, I certify that, when I obtained my out-of-state driver license, I was a permanent resident of the state or province that issued the license, that license has been valid for at least 6 months, and I have not failed a driving skills road test in New York State in the last 12 months. If I am applying for a Conditional or Restricted Use License, I certify that I will pay the full tuition and other required fees for the rehabilitation program (if applicable), attend the program (if required), and will drive within the conditions required for the restricted or conditional license. I understand that failure to do so will result in the revocation of my restricted or conditional license and the reinstatement of the suspension or revocation against my full license. If I am a male at least 18 but less than 26 years old, unless I have opted "no" to United States Selective Service System (SSS) registration on Page 1, I hereby affirmatively opt to register with the SSS and consent to DMV forwarding my personal information to the SSS for registration.
SIGN HERE X DATE:
Noah August Antrim / /
PLEASE PRINT NAME
OFFICE EYE TEST RESULTS Applicant’s Signature Examiner’s Initials
USE • Passed in Office • Vision Registry • Corrective Lens MV-44 (5/22) PAGE 2 OF 3 NEW YORK STATE VOTER REGISTRATION APPLICATION INFORMATION OFFICE USE ONLY (Please read before you complete application on the other side.) Use the NYS Voter Registration Application To Register You Must: • to Register to Vote in NYS Elections, and/or: •• be a U.S. citizen •• change the name or address on your voter registration •• be 18 years old (you may pre-register at 16 or 17 but cannot vote until you are 18) •• become a member of a political party • not be in prison for a felony conviction •• change your party membership •• not claim the right to vote elsewhere •• pre-register to vote if you are 16 or 17 years of age •• not found to be incompetent by a court
If you do not complete the New York State Voter Registration Application, you will be considered to have declined to register to vote. If you decline to register to vote, the fact that you have declined to register will remain confidential and will be used only for voter registration purposes. If you do register to vote, the office at which you submit a voter registration application will remain confidential and will only be used for voter registration purposes. 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 New York State Board of Elections, 40 North Pearl Street, Albany, NY 12207-2729 (phone: 1-800-469-6872). Your completed application will be sent to the Board of Elections and you will be notified by your County Board of Elections when your application has been processed. If you have any questions about filling out the voter registration application or registering to vote, you should call your County Board of Elections or call 1-800-FOR-VOTE (TDD/TTY dial 711) (only for voter registration questions). If you live in New York City, you should call 1-866-VOTE-NYC. You may also find answers or tools at the New York State Board of Elections website www.elections.ny.gov Información en español: si le interesa obtener este 中文信息：如果您有兴趣获取此信息 日本語での情報：これを入手したい場合 إذا كنت: إذا كنت المعلومات باللغة العربية:المعلومات باللغة العربية formulario en español, llame al 1-800-367-8683 中文表格，请致电 1-800-367-8683 1-800-367-8683 日本語のフォーム、 までお電話ください 1-800-367-8683 اتصل على، نموذج باللغة العربية
NEW YORK STATE VOTER REGISTRATION APPLICATION
Only fill this out if you want to register to vote or change your address or other information with the Board of Elections. Are you a citizen of the U.S.? Will you be 18 years of age or older on or before election day? • Yes • No • Yes • No Are you at least 16 years of age and understand that you must be 18 years of age on or before election day to vote, and that until you will be eighteen years If you answer NO, of age at the time of such election your registration will be marked “pending” and you will be unable to cast a ballot in any election? • Yes • No you cannot register to vote. If you answer NO to both of the prior questions, you cannot register to vote. Have you voted before? Voting information that Your name was • Yes • No has changed: Skip if this has not changed or Your address was Your state or New York State County was: What Year? you have not voted before.
More Information Email Telephone Number
(Optional) Political Party I wish to enroll in a political party: You must make 1 • Democratic party AFFIDAVIT: I swear or affirm that selection. Political party enrollment is optional • Republican party • I am a citizen of the United States. • I will have lived in the county, city, or village for at least 30 days before the election. but that, in order to vote in a primary election of • Conservative party • I meet all requirements to register to vote in New York State. a political party, a voter • Working Families party • This is my signature or mark on the line below. must enroll in that • The above information is true. I understand that if it is not true, I can be convicted political party unless • Other: and fined up to $5,000 and/or jailed for up to four years. state party rules allow otherwise. I do not wish to enroll in any political party and wish to remain an independent voter • No party Sign X Date MV-44 (5/22) PAGE 3 OF 3 reset // clear reset clear
