DRIVER LICENSE / PERMIT / ID CARD APPLICATION
LAST NAME (PRINT LEGAL NAME)
FULL MIDDLE NAME
SOCIAL SECURITY NUMBER
OREGON LICENSE/ID NUMBER DATE OF BIRTH (M-D-Y)
MOTHER'S MAIDEN NAME
Do you want your license/ID card to show that you are an anatomical donor?
APPLICANT’S PLACE OF BIRTH (CITY & STATE OR COUNTRY)
SEX (CIRCLE) HAIR COLOR
MAILING ADDRESS (IF DIFFERENT FROM RESIDENCE ADDRESS)
CITY, STATE, ZIP CODE
Do you now have, or have you ever had, an instruction permit, identification card, commercial driver license or driver license from Oregon issued in your name or any other name or other Oregon driver license number?
Do you now have, or have you ever had, an instruction permit, identification card, commercial driver license or driver license from any other state or country issued in your name or any other name?
Are you currently or have you ever had your license to drive or right to apply for the privilege suspended, revoked, canceled or refused?
LICENSE / ID NUMBER
NAME ON PREVIOUS LICENSE / ID
STATE OR COUNTRY
You are required to report any mental or physical condition or impairment that affects your ability to drive safely. You are not required to report all your health conditions – only those that affect your ability to drive safely. DMV will use your answers to the following questions only for the purpose of determining your eligibility for an Oregon license. If you have a condition or impairment that makes you unable to safely operate a motor vehicle, you are not eligible for a license until you have provided additional medical information and/or passed DMV tests. If you answer “Yes” to any one of the questions below, we will not be able to issue you a license at this time.
1) Do you have a vision condition or impairment that has not been corrected by glasses, contacts or surgery that affects your ability to drive safely?
2) Do you have any physical or mental conditions or impairments that affect your ability to drive safely?
a) What is the condition or impairment?: _______________________________________________________________________________________________
b) Describe how this affects your ability to drive safely: ___________________________________________________________________________________
3) Do you use alcohol, inhalants, or controlled substances to a degree that affects your ability to drive safely?
a) Describe how your use affects your ability to drive safely: _______________________________________________________________________________
I understand: DMV will cancel or suspend my permit, license or ID if I make any false statement or show false evidence of age, identity, legal presence, Social Security Number, full legal name, and/or residence address on this application. If I am convicted of such act(s), I can be fined and/or sentenced to jail. Disclosure of my Social Security Number is mandatory and may be used for: enforcing child support laws; verifying identity and residency; and by other government agencies who request it from DMV. (ORS 25.785, ORS 807.021, ORS 807.050, OAR 735-0620005). I certify the vehicle I will use for the license test has insurance coverage meeting
SIGNATURE OF APPLICANT (FULL LEGAL NAME) the requirements of ORS 806.060. I also certify that I a by ORS 807.0 and ORS 807.400.
For applicants under 18 years of age and their parent or legal guardian: the signatures on this application certify the applicant has complied with the driving experience requirements under