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Click here or scroll down to respond to this candidateMV-Street Address (5/22)APPLICATION FOR PERMIT, DRIVER LICENSE OR NON-DRIVER ID CARDPAGE 1 OF 3PRINT CLEARLY IN BLUE OR BLACK INK. OFFICE USE ONLY This form is also available at dmv.ny.gov Image #APPLYING FOR:License Permit ID cardPURPOSE FOR APPLICATION:New Renew Update Info Change Type Replacement Conditional Restricted Transfer New York to IDENTIFICATION INFORMATIONID NUMBER ON NEW YORK STATE DRIVER LICENSE,Do you now have, or did you ever have a New YorkLEARNER PERMIT, or NON-DRIVER ID CARDdriver 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 NAMEFULL FIRST NAMEFULL MIDDLE NAMEDo you have or did you ever have a driver license that is valid or that expired within the last two years, issued by another U.S. State, the District of Columbia or a Canadian Province? Yes No If Yes, where was it issued?Date of Expiration: Type of License: Out-of-State License ID No.: Month Day YearSUFFIX DATE OF BIRTH SEX HEIGHT EYE COLOR TELEPHONE NUMBER (Home/Mobile) Feet InchesHas 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 reasonfor 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 CountyADDRESS 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 CountyHAS 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). NEW YORK STATE ORGAN AND TISSUE DONATION (You must fill out this section) To enroll in the New York State DonateLifeSM Registry, check the yes box and then sign and date You must answer the following question: below. You are certifying that you are: 16 years of age or older; consenting to donate your organs and Would you like to be added to the Donate Life Registry? tissues for transplantation and research; authorizing DMV to transfer your name and identifying information to the Donate Life Registry; and authorizing Donate Life New York State to give access to Yes (sign and date consent below) this information to federally regulated organ donation organizations and New York State-licensed tissue and eye banks and hospitals, upon your death. ORGAN DONOR will be printed on the front of Skip This Question your DMV photo document. You will receive a confirmation, which will also provide you an opportunity to limit your donation. If you are 16 or 17 years of age, parents/legal guardians may change your decision Check upon this your box to death. make For a $more 1 voluntary information, donation contact to the DLNew Life...Pass York It State On Trust at donatelife.Fund for organ ny.gov.
and tissue donation research and outreach. Your total transaction fee will include the $1. Donor Consent Signature and Date 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 M F X
Area Code PLEASE COMPLETE AND SIGN PAGE 2.LicenseClassSpecialNI NA EI EA ConditionsApproved By Date OfficeCDL Certifications TEENSOtherRestrictionsOFFICE USE ONLYCERTIFICATIONEYE TEST RESULTSPassed in Office Vision Registry Corrective Lens OFFICE Applicants Signature Examiners InitialsUSE Junior License Non-driver ID Card (under 16)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 GuardianSign Here X(Relationship to Applicant) (Date)PARENT/GUARDIAN CONSENTI would like to enroll in the TEENS program to be notified if the under 18 year-old applicant receives a conviction, suspension, revocation or an accident on their license file. For more information about this program, see form MV-1046, How to Enroll in TEENS or MV-1056, TEENS FAQs. This is a FREE service.Teen Electronic Event Notification Service (TEENS) THESE QUESTIONS MUST BE COMPLETED FOR ALL LICENSE/PERMIT TRANSACTIONS COMMERCIAL DRIVER LICENSE APPLICANTS ONLY1. In the past 10 years, was a driver license issued to you from another state in the U.S. or the District of Columbia ?YesNoIf YES, write the name of each one1. Has your driver license, learner permit, or privilege 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 or any other name?Yes NoIf Yes, has your license, permit or privilege been restored, or has your application been approved?Yes No2. Have you received treatment, do you currently receive treatment, or do you take medication for any condition that causes unconsciousness or unawareness (for example, a convulsive disorder, epilepsy, fainting or dizziness, or a heart condition)?Yes NoIf 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.gov3. Do you need a hearing aid and/or full view mirror to drive a motor vehicle?Yes No4. Have you lost the use of a leg, arm, hand or eye?Yes No4a. If you need to renew your driver license and you marked Yes, did this occur since your last driver license?Yes No4b. If you marked NO to 4a, has your condition gotten worse since your last driver license?Yes No3. 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 are age 21 or older and you operate, or expect to operate, interstate(other than for excepted operation).Non-excepted Intrastate (NA) - Certified medical status is required. You are age 18 or older and you operate, or expect to operate, in New York State only (other than for excepted operation).Excepted Interstate (EI) -You are age 18 or older and you operate, or expect to operate, interstate in Excepted Operation ONLY. You must have A3 restriction.Excepted Intrastate (EA) - You are age 18 or older and you operate, or expect to operate, in Excepted Operation ONLY and in New York State 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 Examiners 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. SIGN HERE DATE:PLEASE PRINT NAMEX/ /ID Number on New York State Driver License, Permit or Non-driver ID Card of Consenting Parent or Guardian Above (Required)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. 2. Are you subject to any disqualification under section 383.51, title 49 of Code of Federal Regulations or NYS Law? Yes No MV-44 (5/22)PAGE 2 OF 3Informacin en espaol: si le interesa obtener este formulario en espaol, llame al PHONE NUMBER AVAILABLE PHONE NUMBER AVAILABLE PHONE NUMBER AVAILABLE PHONE NUMBER AVAILABLE : :
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: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.govNEW YORK STATE VOTER REGISTRATION APPLICATIONOnly 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.? Yes NoIf you answer NO,you cannot register to vote.Will you be 18 years of age or older on or before election day? 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 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 If you answer NO to both of the prior questions, you cannot register to vote. Have you voted before? Yes NoWhat Year?Voting information that Your name washas changed:Skip if this has not changed or Your address was Your state or New York State County was: you have not voted before.More Information Email Telephone Number(Optional)I wish to enroll in a political party:You must make 1 Democratic party AFFIDAVIT: I swear or affirm that selection. Political partyPolitical Partyenrollment 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 in a that, primary in order election to vote 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. The above information is true. I understand that if it is not true, I can be convicted political party unless Other:must enroll in thatand fined up to $5,000 and/or jailed for up to four years. state party rules allowotherwise. I do not wish to enroll in any political party and wish to remain an independent voter No party SignXDateMV-44 (5/22) reset / clear PAGE 3 OF 3 |
