Form Dl 1p - Driver'S License And Identification Card Application
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2Completion 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?
NO
YES
NO
YES
(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.
DL 1P (07/01/2013)
DRIVER'S LICENSE AND IDENTIFICATION CARD APPLICATION
LOG #
Purpose:
Use this form to apply for a Virginia Driver's License or Identification Card.
Instructions:
Complete the front and back of this application.
Note: Effective July 1, 2011, a $5 service fee applies to each license or ID card renewal
transaction conducted in a CSC, unless the renewal is conducted with another transaction that cannot be completed by internet, automated
telephone or mail.
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)
Driver's License with School Bus Endorsement
1.
Identification (ID) Card
Driver's License
7.
4.
(to carry less than 16 passengers)
Hearing Impaired ID Card
Learner's Permit and Driver's License
2.
8.
5.
Driver's License Testing for Foreign Diplomats
Motorcycle Learner's Permit
Emancipated Minor ID Card
9.
3.
CDL Instruction Permit or License
(classification not applicable)
6.
10. Motorcycle
Renew Virginia
Motorcycle Only License
New/Upgrade/Transfer Motorcycle Class
(also check one below)
(also check one below)
Motorcycle Class
M 2
M 3
M
M 2
M 3
M
(2 wheels)
(3 wheels)
(both 2 wheels and 3 wheels)
(2 wheels)
(3 wheels)
(both 2 wheels and 3 wheels)
Replacement license or identification card
I am surrendering my current license or ID card.
11.
(check one of the following):
Lost
Stolen
Destroyed or Mutilated
I certify I cannot surrender my current license or ID card because it is:
Yes
No
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?
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)
WEIGHT
HEIGHT
EYE COLOR
HAIR COLOR
(
)
LBS.
FT.
IN.
MALE
FEMALE
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 - this address will show on your license/ID card)
APT NO.
CITY
STATE ZIP CODE
SPECIAL INDICATOR REQUEST
1.
Do you wear glasses or contact lenses?
YES
NO
I am insulin-dependent or have a speech or hearing
2.
Do you have a physical or mental condition which requires that you take medication?
YES
NO
impairment and want the following indicator(s) to
3.
Have you ever had a seizure, blackout, or loss of consciousness?
YES
NO
show on my license ;
4.
Do you have a physical condition which requires you to use special equipment in order to drive?
YES
NO
Insulin-dependent diabetic
5.
Have you been convicted within the past ten years in this state or elsewhere of any offense
YES
NO
Speech impairment
resulting from your operation of, or involving, a motor vehicle? (Do not include parking tickets.)
Hearing impairment
6.
Has your license or privilege to drive ever been suspended, revoked, or disqualified in this state
YES
NO
Must submit required physician statement
or elsewhere, or is it currently suspended, revoked or disqualified?
If you answered YES to any of the above provide an explanation here.
FOR DMV USE ONLY — DO NOT WRITE BELOW THIS LINE
CUSTOMER NUMBER
TRANSACTION TYPE
FEE
REQUIRED TESTS
PASS
FAIL
ORIGINAL
REISSUE
DUPLICATE
RENEWAL
VISION
DL ROAD SIGNS EXAM
PROOF OF ID (primary)
PROOF OF ID (secondary)
DL KNOWLEDGE EXAM
PROOF OF SOCIAL SECURITY (specify)
PROOF OF RESIDENCY
DL SKILLS
PROOF OF LEGAL PRESENCE (specify)
REMARKS/PAID STAMP
Document Type
Document Number
Expiration Date (mm/dd/yyyy)
Document Number
Document Type
Expiration Date (mm/dd/yyyy)
Document Number
Document Type
Expiration Date (mm/dd/yyyy)
DOCUMENT VERIFIER SIGNATURE AND LOGONID
CSR SIGNATURE AND LOGONID
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