IT IS IMPORTANT THAT YOU READ AND UNDERSTAND
THE FOLLOWING INFORMATION AND CERTIFICATIONS
The following conditions that may affect your ability to operate a motor vehicle safely include, but are not limited to:
•loss of consciousness; or
•episode of marked confusion caused by any condition which may bring about recurring lapses; or
•disease, disorder, or disability (examples of these are epilepsy, diabetes, stroke, cataracts, Parkinson’s disease); or
•decrease or change in your vision due to cataracts, macular degeneration, diabetic retinopathy, glaucoma, retinitis pigmentosa, or other progressive condition; or
•health problems because of alcohol or drug abuse.
If the voter has not received voter registration information within 30 days of requesting it, they should contact the Local Elections Ofﬁce of the Ofﬁce of the Secretary of State.
ORGAN DONOR STATEMENT
If you marked on the front of the application that you want to be an organ and tissue donor upon death, your consent shall serve as a legally binding document as outlined under the California Uniform Anatomical Gift Act. Except in the case where the donor is under the age of 18, the donation does not require the consent of any other person. For donors under the age of 18, the legal guardian of the donor shall make the ﬁnal decision regarding the donation. If you want to change your decision to consent in the future, or if you want to limit the donation to speciﬁc organs, tissues or research, you must contact Donate Life California by mail at 1760 Creekside Oaks Drive, # 220, Sacramento, CA 95833 or online at www.donateLIFEcalifornia.org,
•SOCIAL SECURITY NUMBER COLLECTION DISCLOSURE — You are required by law to provide your Social Se- curity Number, if you are eligible for one, or your application will be denied. An applicant who is legally present in the United States, but not authorized to work and therefore ineligible for a Social Security Number may still be eligible for a California Driver License/Identification Card.
Authority to collect the social security number is United States Code, Title 42, Chapter 7, Subchapter II, Section 405 and California Vehicle Code §1653.5, §12800, and §12801. It will be used in the administration of driver license laws and motor vehicle registration laws and to respond to requests for information from the:
•Franchise Tax Board for tax administration
•Any agency operating pursuant to 42 U.S.C. 601 et seq.
It will be used to aid in the collection of monies owed in connection with:
3 failure to pay ﬁnes or failure to appear in court by an applicant 3 Aid to Families with Dependent Children
3 Child Support
3 Establishment of Paternity
•DMV verifies your social security number, name and birth date on our records with the Social Security Administration. You will not be issued or be able to renew your driver license or identiﬁcation card until the Social Security Administration veriﬁes the information you have provided is correct. By applying for a driver license or identiﬁcation card, you authorize and consent to a search of any and all databases at the Social Security Administration by the California Department of Motor Vehicles, to verify the information you have provided.
•DMV checks for driving record status in other jurisdictions through the National Driver Registry prior to issuance of a California driver license. You will not be issued a California driver license if another jurisdiction has withdrawn your driving privilege.
•The mailing address listed on the front of this application will be the address shown on your driver license or identification card.
The information required on this form pertains to eligibility for and issuance of a driver license. It is required under the authority of Division 6 of the California Vehicle Code. Failure to provide the information is cause for refusal to issue a driver license, or, in some cases, cancellation or withdrawal of the driving privilege.
•Except as made confidential (medical information is confidential under authority of California Vehicle Code §1808.5) or exempted under the Public Records Act, this information is a public record and is regularly used by law enforcement agencies and insurance companies.
•Access to address information is now restricted, and will be available to various authorized requesters for limited use. Individuals can obtain copies of their own information during regular ofﬁce hours.
•If you submit fraudulent information, the DMV may pursue criminal prosecution.
•Any person who uses false documents to conceal his or her true citizenship or resident alien status is guilty of a felony pursuant to California Penal Code §114.
• Once this application form and fee have been submitted, no refunds will be made.
•I agree to submit to a chemical test of my blood, breath, or urine for the purpose of determining the alcohol or drug content of my blood when testing is requested by a peace ofﬁcer acting in accordance with California Vehicle Code §23612.
•I am hereby advised that being under the influence of alcohol or drugs, or both, impairs the ability to safely operate a motor vehicle. Therefore, it is extremely dangerous to human life to drive while under the inﬂuence of alcohol or drugs, or both. If I drive while under the inﬂuence of alcohol or drugs, or both, and as a result, a person is killed, I can be charged with murder.
•By signing this application, I certify that I was notified that if I am under 21 years of age, I cannot legally drive with a blood alcohol concentration (BAC) of 0.01% or more. Driving with a BAC of 0.01% or more, or refusing to take, or failing to complete an alcohol screening or drug test, results in a one-year suspension of my driving privilege.
•By signing this application, I certify that I was notified that if I am currently on court probation for a driving under the influence offense, I cannot legally drive with a blood alcohol concentration (BAC) of .01% or more. Driving with a BAC of .01% or more results in a one-year suspension of my driving privilege. Refusing to take, or failing to complete an alcohol screening or chemical test will result in a two to three year suspension/revocation of my driving privilege.
•I am the person whose name appears on the front of this form. The mailing address shown is valid, existing, and accurate. I agree to accept service of process at this mailing address according to §§415.20(b), 415.30(a), and §416.90 of the California Civil Procedure Code.
•I understand DMV may add traffic convictions reported by other states or jurisdictions to my driving record that may result in sanctions against my California driving privilege.
•By signing this form, I am acknowledging my presence in the United States is authorized under federal law.
•I understand I may have no more than one driver license in my possession or under my control in accordance with California Vehicle Code §12511.