Wisconsindmv Mv3001 – Fill Out and Use This PDF

WISCONSIN DRIVER LICENSE (DL) APPLICATION

An unexpired Wisconsin

Wisconsin Department of Transportation

MV3001

7/2021

Ch. 343 Wis. Stats.

driver license is acceptable

Clear Form

Print

photo ID for voting.

ALL APPLICANTS – Please Print

(s. 5.02(6m) Wis. Stats.)

Social Security Number

Applicant Name – First, Middle, Last

Birth Date (mm/dd/yyyy)

Residence Address – Street

Apt #

City

State

ZIP Code

Mailing Address – ONLY IF DIFFERENT from Residence

Apt #

City

State

ZIP Code

Sex

Race

Eyes

Hair

Weight

Height

Former Name (if changed since last license or ID card)

Reason for Name Change

Marriage  Divorce  Other  List:

1. Do you wish to register to be an organ, tissue and eye donor?

YES 

7. Will you donate $2 to organ, tissue and eye donation efforts?

YES 

2. OPT OUT – Do you wish to have your name and address

YES 

8. Do you need glasses or contact lenses for driving?

YES NO

withheld from lists WisDOT sells?

 

3. I am a veteran registered with WDVA and wish to have my

YES 

9. Do you have any physical limitations which interfere with

YES NO

veteran status indicated on my driver license. (DMV is

your ability to perform the normal tasks associated with

 

required to verify your status with WDVA)

operating a motor vehicle?

If yes, have you successfully passed a road test with this

YES NO

4. Has your license, ID card or operating privilege ever been

YES NO

revoked, suspended, cancelled, disqualified or denied?

 

condition?

 

If yes, list date and place:

10. In the past year have you had a loss of consciousness or

YES NO

5. Have you been convicted of operating while intoxicated

YES NO

muscle control caused by any of the following conditions?

 

OUTSIDE of Wisconsin?

 

If yes, check condition(s) and list date(s):

If yes, give date and place:

Traumatic Brain or

Muscle or

Seizure

6. Do you hold a valid driver license/identification card from

YES NO

Head Injury (2) 

Nerve (2) 

Disorder (4) 

Heart (6) 

Stroke (2) 

Mental (3) 

Diabetes (5) 

Lung (7) 

another state/country?

 

If yes, list:

11. Check ONLY ONE of the following three boxes.

Years of licensed driving experience in the United States, its

I certify that I am a:

territories and Canada. List:

 U.S. Citizen

 Temporary Visitor

 Permanent or Conditional Permanent Resident

(Applicant Signature)

(Date)

OFFICE USE ONLY

Reason for Reissue:

Date

Processor ID

Product Type

 REAL ID



REGI



CLP



CYCI



SPRI



JUVI



MPDI

Wisconsin or Out-of-State License Number

State

Expiration Date

 PROB  RGLR  OCCL  SPRR  JUVP  NON

Hearing (CDL Only)

Examiner ID

Application Type

Skill Test Score

Highway Signs

Knowledge

Class(es) Issued

Endorsements

 A  B  C

 D  M

 H

 N  P  S  T  F

Payment

Amount

 Check  Cash

 CC  Acct.

$

(Processor Signature)

(Processor ID)

VISION

 Check if vision section completed by DMV Examiner

Temporal Field of

Being duly licensed to practice

 Wisconsin, or  Other

Visual Acuity

Without RX

With RX

Vision In Degrees

 Optometry  Medicine, in:

Name of State or Country

Right Eye

20/

20/

Left Eye

20/

20/

I certify that the findings are correct

and I examined this applicant on:

(Exam Date)

Corrective lenses required while driving

Color Perception

 YES  NO

 Normal  Deficient

Progressive eye disease or cataracts

If Yes, to Progressive eye disease or cataracts

X

 YES  NO

 One Eye

 Both Eyes

(Eye Examiner Signature)

(License #)