Dld6A Form – Fill Out and Use This PDF

The Dld6A form is a comprehensive document required by individuals in Utah applying for or renewing a driver license or identification card. It captures a wide range of personal information, including name, date of birth, Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN), address, gender, eye color, and hair color, along with questions about health conditions that might affect driving ability, legal status, and voting preferences. Filling out the Dld6A form accurately is crucial for maintaining driving privileges and ensuring that your legal documents reflect your current status. Interested individuals are encouraged to carefully complete the form and click the button below to proceed with their application.

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Dld6A Form PDF Details

Understanding the complexities of obtaining or renewing a driver's license or state identification card involves navigating through various forms, one of which is the Dld6A form. This comprehensive document is essential for applicants in Utah, catering to a wide range of information that includes personal identification details such as the Utah license number, ID number, full legal name, date of birth, social security number or individual taxpayer identification number, and much more. In addition to basic identification, the form delves into specific aspects such as visual acuity, testing requirements for driving, legal presence verification, medical conditions that may affect driving ability, and the applicant's desire to make anatomical gifts. Equally important, the form addresses the applicant's citizenship status, eligibility for a veteran indicator, and whether they are required to register as a sex offender or wish to register to vote. Applicants are reminded of the legal implications of failing to answer questions truthfully, highlighting the form's role not only in administrative processing but also in ensuring public safety and legal compliance. With sections dedicated to fees, donations to charitable causes, and detailed inquiries regarding health conditions potentially impacting driving capabilities, the Dld6A form represents a critical step in the licensing process, ensuring individuals meet all necessary criteria for operating a vehicle safely.

Question	Answer
Form Name	Dld6A Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	DLD6AONLINEAPP1 14 dld6a form 2013

Form Preview Example

UT LICENSE #			UT ID #


Last Name			Date of Birth
First Name			SSN or ITIN


			This info will not show on your DL or ID
			This info will not show on your DL or ID
Middle			Phone


Suffix	Gender	Email


UT Residence Address




	City			Zip Code


Mailing Address

DLD Office Use Only:
		$15 LERN		ORG LERN
DPC		DL	CDL			ID		IDD
	LTID		LTDL		LTCDL			MVP
Class:	A		B		C			D
Endorsement:		H	N	X	Z	P	S	T M
Visual Acuity:		Passed				Eye Statement
Restrictions:		A	B K	L	G	V	6	J:___
Motorcycle Restrictions:				0	2		3	5

City

Height				Weight
	FT.		IN.
Applicant’s					Mother’s
Applicant’s					Mother’s
Place of					Maiden
Birth		State/Country			Name

State		Zip Code



	Hair Color		Eye Color


	Last		First

Testing:	Written	Road	Refugee/Asylee
Station:______	Emp #:_______		Initials:_______
	NAME CHANGE
From:________________		To:___________________
ID #1:________________		ID #2:________________

NOTICE: APPLICANT MUST ANSWER ALL QUESTIONS. FAILURE TO TRUTHFULLY COMPLETE QUESTIONS MAY RESULT IN WITHDRAWAL OF DRIVING PRIVILEGE OR IDENTIFICATION CARD.

YES	NO	Are you a U.S. Citizen?
		YES	NO	Are you a legal permanent resident alien or a U.S.
				National?
		YES	NO	If you are a citizen of another country, do you have
				evidence of lawful presence in the United States?
YES	NO	I would like to register my desire to be an organ, eye, and tissue donor
		(lifesaving anatomical gift.)
YES	NO	Are you a U.S. Military Veteran?
YES	NO	If yes, do you authorize sharing this information with the Utah Division of
		Veterans Affairs for the purpose of identifying veterans and disseminating
		veteran benefit information?
YES	NO	If you have been honorably discharged from the U.S. Military, would you like
		to have a VETERAN indicator on your driver license or ID card?
YES	NO	Are you required to register as a sex offender with the State of Utah, any
		other state, or with the U.S. Government?
YES	NO	If you are not registered to vote where you live now, would you like to
		register to vote today? (U.S. Citizens Only)
YES	NO	If you are 16 or 17 years of age, and will not be 18 years of age before the
		date of the next election, would you like to preregister to vote today?
YES	NO	Do you now have, or have you ever been issued, a driver license by another
		state, country or province? If yes, list states/countries/provinces:
		____#_________Exp. Date______			____#_________Exp. Date______
		____#_________Exp. Date______			____#_________Exp. Date______
YES	NO	If you are a CDL driver, have you been licensed in another state within the
		last 10 years? If yes, please list:
		____#_________Exp. Date______			____#_________Exp. Date______
		____#_________Exp. Date______			____#_________Exp. Date______
YES	NO	In the last 10 years, has your driving			privilege been suspended, revoked,
		canceled, denied or disqualified? If yes, State:____ #________________
		Why_______________________________________________________
YES	NO	Are you required to carry a medical certificate (DOT Card?) If yes, are you in
		compliance? ____________ Certificate expires: _________________
YES	NO	Do you wish to contribute a $2.00 donation to the “Friends for Sight” fund?
YES	NO	Do you wish to contribute $2.00 to educate people about organ, eye and
		tissue donation?
YES	NO	Do you wish to contribute a $1.00 donation to the “Mobility Assistance
		Fund?”
YES	NO	Do you claim to be disabled under the Americans with Disabilities Act?
YES	NO	Do you claim to be indigent and are applying for an ID card for voting
		purposes?

Print the name of the person signing for minor:

Father	Mother	Guardian
ID Card	Lapsed	License Fee	$__________	Total $ ____________
Original	Lapsed 65	Reinstate Fee	$__________	Transaction # ______
Provisional	Upgrade	Admin Fee	$__________	Initials: ___________
$15 Learner Permit	Upgrade Previous Lic	ID Fee	$__________
Renewal	Downgrade	Charity Fee(s)	$__________	Cash	Check
Renewal 65	Retest Fee			Credit/Debit	Voucher
Duplicate	MVP	Other	$__________

Legal Presence:________________________________

BC NAME

Full Legal Name:________________________________

DOB:____/____/____				Iss. Date:____/____/____
BC PP DHS #:_________				Iss. Agency:___________
Required Docs Scanned Date:_____________________
			SSN, ADDRESS, SAVE
SSN:____-____-____				Date:_________________
SSV:	Yes / Override			Date:_________________
Address Verified Date:__________
SAVE: 2nd:__________					3rd:__________
Approved Final Date:__________						Exp.:__________
Denied Date:__________				Employee #:___________
				CDL
	CDLIS			CSR		CDR
SI:__________			SI:__________			SI:__________
	UA:__________ CSR:__________
Match		No Match		Eligible		Not Eligible
Pending				Error		License
			PDPS
SB:__________			License Surrender: Y / N
CDL: Y / N		10-Year History: Received / Completed
Issued:__________				Expired:__________
State:_____		Endorsement:___			License #:________

DLD6a Rev. 5/15

UT LICENSE #

UT ID #

Last Name

DOB

Examiner Notes and Completed Date Stamp:

Individuals who apply for or hold a license and have, or develop, or suspect that they have developed a physical, mental, or emotional impairment that may affect driving safety are responsible for reporting this to the division or its agent.

DO YOU HAVE, OR HAVE YOU HAD, ANY OF THE FOLLOWING CONDITIONS IN THE LAST FIVE YEARS?

YES	NO	A	Diabetes		Diabetes (high blood sugar, sugar diabetes you control with diet, medication or insulin) or
					hypoglycemia or other metabolic condition etc., which may interfere with driving safety?
YES	NO	B	Cardiovascular		Heart condition, with or without symptoms (heart attack, heart surgery, irregular rhythm, general heart
					disease) within the last five years; or hypertension (high blood pressure) unable to be controlled with
					medication?
YES	NO	C	Pulmonary		Pulmonary (lung) condition (asthma, emphysema, passing out from coughing, etc.) shortness of
					breath which has required treatment?
			YES	NO	Is an inhaler the only medication prescribed for this condition?
			YES	NO	Are you required to use supplemental oxygen while driving?
YES	NO	D	Neurologic		Neurological condition (stroke, head injury, cerebral palsy, multiple sclerosis, muscular dystrophy,
					Parkinson’s disease, etc.) which may interfere with driving safety?
YES	NO	E	Epilepsy		Seizures or other episodic conditions which include any recurrent loss of consciousness or control?
			YES	NO	Commercial: Anytime during your life.
YES	NO	F	Learning and		Learning and memory difficulties which may interfere with driving safety?
			Memory
YES	NO	G	Psychiatric		Psychological condition (severe anxiety, severe depression, severe behavioral mood conditions,
					schizophrenia, etc.) or other conditions for which hospitalization has occurred or been recommended
					by a physician or other mental health professional?
YES	NO	H	Alcohol and		Excessive use of alcohol and/or prescription drugs, or use of any illegal drugs; or treatment or
			Drugs		recommendation for treatment of alcohol use or chemical dependency?
YES	NO	I	Vision		Do you wear glasses or contact lenses for driving?
			YES	NO	Is your visual acuity worse than 20/40 in the better eye, even with corrective lenses?
			YES	NO	Do you have degenerative or progressive eye condition?
			YES	NO	Have you experienced a decrease in peripheral (side) vision?
YES	NO	J	Musculoskeletal		Loss or paralysis of all or part of an extremity; or onset of a general debilitating illness requiring
			Chronic Debilities		treatment?
			YES	NO	New or changed in the past 5 years?
			YES	NO	Present longer than 5 years?
YES	NO	K	Alertness or		Do you have a condition that produces abnormal sleepiness (sleep apnea, narcolepsy, etc.?)
			Sleep Disorders
YES	NO	L	Hearing		Only if you are a Commercial driver – no hearing requirements have been established for Regular
			Impairment		Operator license.
YES	NO		Balance (ENT		Have you experienced any sudden vertigo or infection of the inner ear (vestibular neuronitis or
			Problems)		labryinthitis?)
YES	NO		Other		Other health problems or use of medications which might interfere with driving ability or safety? Please
					explain: _____________________________________________________________________

Answering yes to any of the above questions may result in a request for additional follow-up information.

Please print and take this completed form with you to the office.

How to Edit Dld6A Form Online for Free

If you wish to fill out Dld6A Form, you don't need to download and install any sort of programs - simply use our online PDF editor. In order to make our editor better and easier to use, we constantly develop new features, taking into consideration feedback from our users. In case you are seeking to begin, here's what it's going to take:

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Step 2: This editor offers the capability to customize your PDF form in a variety of ways. Improve it by writing personalized text, correct what is already in the document, and include a signature - all close at hand!

It's straightforward to finish the pdf using out detailed tutorial! Here's what you have to do:

1. Complete the Dld6A Form with a selection of necessary blank fields. Consider all the required information and ensure absolutely nothing is neglected!

2. After the last segment is finished, you're ready to insert the necessary particulars in Last Name First Name Middle Suffix, YES, NO Are you a US Citizen, YES, NO Are you a legal permanent, YES, YES, National If you are a citizen of, YES YES, NO Are you a US Military Veteran NO, YES, NO Are you required to register as, If yes do you authorize sharing, other state or with the US, and YES so you can move forward to the third part.

NO Are you a US Citizen, YES, and other state or with the US of Dld6A Form

As for NO Are you a US Citizen and YES, be sure you review things in this current part. These two are the key fields in the form.

3. The next section is normally quite simple, YES, NO Are you required to carry a, YES YES, YES, compliance Certificate expires, NO Do you wish to contribute a, tissue donation, NO Do you wish to contribute a, Fund, YES YES, NO Do you claim to be disabled, purposes, UA CSR, Match, and No Match - all of these form fields will have to be filled in here.

4. This next section requires some additional information. Ensure you complete all the necessary fields - UT LICENSE, UT ID, Last Name, DOB, Examiner Notes and Completed Date, Individuals who apply for or hold, or emotional impairment that may, DO YOU HAVE OR HAVE YOU HAD ANY OF, YES, NO A Diabetes, YES, NO B Cardiovascular, YES, NO C Pulmonary, and YES - to proceed further in your process!

DOB, DO YOU HAVE OR HAVE YOU HAD ANY OF, and Individuals who apply for or hold inside Dld6A Form

5. Lastly, the following last subsection is what you have to wrap up prior to closing the form. The fields in question include the following: YES, NO Commercial Anytime during your, Learning and memory difficulties, Psychological condition severe, Do you wear glasses or contact, Do you have degenerative or, YES, NO F, Learning and Memory, YES, NO G Psychiatric, YES, NO H Alcohol and, YES, and Drugs Vision.

YES, NO Commercial Anytime during your, and YES of Dld6A Form

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Dld6A Form – Fill Out and Use This PDF

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