Form DL-14A– Fill Out and Use This PDF

APPLICATION for:

DRIVER LICENSE

COMMERCIAL DRIVER LICENSE (CDL)

LEARNER LICENSE

IDENTIFICATION CARD

NON-RESIDENT COMMERCIAL DRIVER LICENSE

Class (Circle) A B C M

APPLICANT INFORMATION

CONTACT INFORMATION

LAST NAME:

HOME PHONE:

FIRST NAME:

OTHER PHONE:

MIDDLE NAME:

EMAIL:

SUFFIX:

ADDRESS INFORMATION

MAIDEN NAME:

RESIDENCE ADDRESS:

DATE OF BIRTH (mm/dd/yyyy):

—

—

CITY:

STATE:

SSN:

—

—

ZIP CODE:

COUNTY:

SEX: (Circle One)

MALE

FEMALE

MAILING ADDRESS:

EYE COLOR:

HAIR COLOR:

RACE/ETHNICITY:

(I) American Indian/Alaska Native

CITY:

STATE:

(A) Asian/Pacific Islander (B) Black (H) Hispanic

(O) Other (W) White

ZIP CODE:

COUNTY:

HEIGHT: ft.

in.

WEIGHT: lbs.

PLACE OF BIRTH: CITY:

COUNTY:

STATE:

COUNTRY:

FATHER’S LAST NAME:

MOTHER’S MAIDEN NAME:

REQUIRED INFORMATION FROM ALL APPLICANTS

YES NO

1.

Are you a citizen of the United States?

2.

If you are a US citizen, would you like to register to vote? If registered, would you like to update your voter information?

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.

Do you wish to donate $1.00 to the Blindness Education Screening and Treatment Program?

4.

Do you wish to donate $1.00 to the Glenda Dawson Donate Life – Texas Registry?

5.

Would you like to register as an organ donor?

6.

Do you have a health condition that may impede communication with a peace officer? If yes, please list

(must complete form DL-101)

7.

a)

Do you want a Veteran designator on your driver license or identification card? (proof of Honorable discharge required; acceptable

documents are DD214/5, NGB22, or VA disability letter noting characterization of service)

b) Are you a 60% disabled Veteran receiving compensation and want to waive the application fee? (see 7a for documents required)

8.

Have you ever had a Texas identification card?

Number

When?

9.

Have you ever had a driver license or instruction permit in Texas?

Number

When?

10.

Have you ever had a license or instruction permit in any other state? List state(s)

Number(s)

When?

REQUIRED INFORMATION FROM DRIVER LICENSE APPLICANTS

YES NO

DRIVING HISTORY INFORMATION

11.

Are you enrolled in or have you completed an approved driver education course?

12.

Is your driver license or driver privilege CURRENTLY or EVER been suspended, revoked, canceled, denied or disqualified in ANY state?

Where?

When?

Why?

VEHICLE REGISTRATION AND INSURANCE INFORMATION

13.

Do you own a motor vehicle which is required to be registered (Texas Transportation Code Section 502.040)?

14.

Do you own a motor vehicle which 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)?

UNITED STATES SELECTIVE SERVICE

Any male United States citizen or immigrant who is at least 18 years of age but less than 26 years of age submitting this application consents to registration withtheUnitedStatesSelectiveServiceSystem.Youmustberegisteredtoqualifyforfederalstudentaid(toincludePellgrant),jobtraining,federalemployment, and citizenship if an immigrant. In Texas, you must be registered to qualify for state college student aid or state employment. If convicted, failure to register with the Selective Service 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 could permanently lose those benefits associated with registration. For alternative options for applicants who object to conventional military service for religious or other conscientious reasons information is available at: http://www.sss.gov/FactSheets/FSaltsvc.pdf.

DL-14A (Rev. 3/14)

APPLICATION CONTINUED ONBACK

DRIVER LICENSE APPLICANTS

Answers to 1 through 7 below are for the confidential use of the Department.

YES NO	MEDICAL HISTORY QUESTIONS
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 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 medical condition:

NOTICE: The information on this application is required by the Texas Driver License Act, Texas Transportation Code Chapter 521. Failure to provide the information is cause for refusal to issue a driver license or identification card, and in some cases, cancellation or withdrawal of driving privileges. False information could also lead to criminal charges with penalties of a fine up to $4,000.00 and/or jail.

DO NOT SIGN BELOW UNTIL INSTRUCTED TO DO SO BY NOTARY PUBLIC OR DRIVER LICENSE EMPLOYEE.

CERTIFICATION

I do solemnly swear, affirm, or certify that I am the person named herein and that the statements on this application are true and correct. I further certify my residence address is a (check one): ( ) single family dwelling, ( ) apartment, ( ) motel, ( ) temporary shelter. I agree to immediately report to the Texas Department of Public Safety any changes in my medical condition which may affect my ability to safely

operate a motor vehicle. I further understand that I am required by law to report any change of name or address to the Department of Public
Safety within thirty days.	X
	Signature of Applicant		Date

Texas law requires the Texas Department of Public Safety must provide every minor applicant (under age 18), and cosigner, for a driver license in Texas, educational information concerning state laws relating to driving while intoxicated, driving by a minor with alcohol in the minor’s sys- tem, and the implied consent law. The minor applicant and the cosigner must acknowledge receipt of that information prior to issuance of any driver license or permit.

I hereby acknowledge receipt of the information concerning DWI, the Zero Tolerance Law and the Implied Consent Law.

Minor ApplicantParent/Legal GuardianDate of Receipt

PARENTAL AUTHORIZATION

Required for all driver license applicants under the age of 18

I do solemnly swear, affirm, or certify that I am the person named herein, that the statements on this application are true and correct, that the above named applicant is my ( ) child ( ) stepchild ( ) ward, and that I have legal custody of the applicant. I authorize the Department of Public Safety to issue a Class ( ) A, ( ) B, ( ) C, or ( ) M license to said minor. The Department can access the said minor’s school enrollment records from the Texas Education Agency, and a school administrator or law enforcement officer is authorized to notify the Department if the said minor is absent from school for at least 20 consecutive instructional days.

Usual Written Signature of Parent or Guardian		Driver License Number					Date
	WAIVER OF PARENTAL AUTHORIZATION
Parental Authorization waived.
Signature of Applicant					DL Employee				ACID
		VERIFICATION
Sworn to and subscribed before me this			day of				,

Notary Public in and for the State of Texas/Authorized Officer

SOCIAL SECURITY NUMBER COLLECTION DISCLOSURE

Disclosure of your social security account number is mandatory for driver license applicants, but voluntary for identification card applicants. This information is solicited pursuant to 42 U.S.C. 405(c)(2)(C)(i), 42 U.S.C. 666(a)(13)(A); 49 C.F.R. 383.153, Texas Family Code Section 231.302(c)(1) and Texas Transportation Code Sections 522.021 and 521.142. The Department will use social security number information for identification purposes and will only release the number to the Child Support Enforcement Division of theAttorney General’s Office, the U.S. Selective ServiceAdministration, theTexas Secretary of State and the Health and Human Services Commission for statutorily authorized purposes pursuant to Texas Transportation Code Section 521.044.