Dl 14A Form – Fill Out and Use This PDF

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

Suffix:__________________________________ Birth Surname (Maiden):_________________________________________

-

-

SSN:________________________________

Date of Birth (mm/dd/yyyy):_____________________

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:_______________________________________________________

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

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?

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)