License Application 478

User Manual: 478

Open the PDF directly: View PDF PDF.
Page Count: 1

DownloadLicense Application 478
Open PDF In BrowserView PDF
STATE OF ALASKA
DIVISION OF MOTOR VEHICLES

APPLICATION FOR ALASKA DRIVER LICENSE,
PERMIT OR IDENTIFICATION CARD
LICENSE / PERMIT

478
FULL
LEGAL
NAME:

CLASSIFICATION

 Driver License
 Instruction Permit

 Non-Commercial (D)
 Motorcycle

 Identification Card
First

CDL

AK license / permit / ID number, if applicable.
PLACE
OF
BIRTH:

 A B
Middle

Date of Birth

ENDORSEMENTS
 Hazardous
 Tank (N)

 C

Height
ft

State

 Doubles / Triples
Suffix

Tank (N) + HazMat (H)
Last

Sex

City

 Passenger (P)
 School Bus (S)

Weight

Hair Color

Eye Color

in

Country (If other than USA)

Social Security Number

Mailing Address (This address will appear on the license, permit or ID.)

City

State

Zip Code

Residence Address (Physical location – no PO Box or Mail Receiving Station addresses.)

City

State

Zip Code

Email

Phone #

VETERAN

ORGAN DONOR

VOTER
REGISTRATION

PREVIOUS
NAMES

I declare myself an honorably discharged US Armed Forces veteran and authorize DMV to send my personal information to the
Dept. of Military and Veterans Affairs to provide benefits to me.

 YES

 NO

I have a US Armed Forces honorable discharge and wish to have a veteran designation placed / retained on my license.

 YES

 NO

Would you like to be an organ donor with a designator displayed on your license / ID card?

 YES

 NO

Would you like to donate $1 or more to the anatomical gift awareness fund? If so, how much?

$

Would you like to register to vote or make changes to your voter registration

 YES  NO

Are you a U.S. Citizen? You may not register to vote if you are not a U.S. citizen.

 YES  NO

Have been convicted of a felony?

 YES  NO
 YES  NO

Have you been unconditionally discharged?
Would you like your residence address kept confidential? (Your residence address must be DIFFERENT than your mailing
address to be kept confidential.)
If you are already registered to vote in the State of Alaska, this form will update your voter registration address.
Do you want your address updated for voter registration purposes?
(In order to be a registered voter of Alaska, you must provide an Alaska residence address.)

 YES  NO
 YES  NO

List any previous / maiden names by which you have been known:
List any States in which you have ever held a permit, license or id card:
Have your driving privileges ever been suspended or revoked or application for license refused?

DRIVER
LICENSE
QUESTIONS
(You do not need to
answer these
questions for an ID
card)

State:

Date:

Reason:

State:

Date:

Reason:

Within the past 5 years, have you had a medical condition or impairment, mental or physical disorder, seizure, or any other
health problems that could affect your ability to safely operate a motor vehicle?

 YES

 NO

 YES

 NO

 YES

 NO

If yes, please explain:
Within the last five years, have you had three or more alcohol or drug related convictions?
If yes, you must provide physician verification that the problem is under control or proof of completion of a rehabilitative treatment program

COMMERCIAL
Are you domiciled (permanent residence) in the State of Alaska?
 YES  NO
DRIVERS ONLY
I acknowledge that receiving an Alaska Permit, License or ID card may cancel or invalidate any Permit, License or ID card from another state per the laws of that state. I have personally reviewed the
information on this application and certify under penalty of perjury that to the best of my knowledge and belief the information on this application is true and correct. NOTE: Making a false statement in
connection with this application may be punishable by a maximum penalty of $50,000 or five years imprisonment or both per AS 11.46.505.

X
Signature of Applicant (MUST SIGN IN FRONT OF A DMV REPRESENTATIVE)

Date

LOGIN ID / Office Number

*****DMV USE ONLY *****
VISION
TEST

With CL

Left

Both

Right

Without CL

20/

20/

20/

Vision Notes

CDL Color Blind Test:
Pass / Fail / Medical Card

DOCUMENTS SEEN / OTHER NOTES

(Rev.08/14/2017)

Alaska.gov/dmv

LICENSE
ISSUED

 Orig
Class:

 Renew

 Duplicate



Source Exif Data:
File Type                       : PDF
File Type Extension             : pdf
MIME Type                       : application/pdf
PDF Version                     : 1.6
Linearized                      : No
Author                          : Debbie Smith
Comments                        : 
Company                         : State of Alaska, Dept of Admin, DIS
Create Date                     : 2017:08:14 16:08:46-08:00
Modify Date                     : 2018:01:18 14:30:19-09:00
Source Modified                 : D:20170815000835
Subject                         : 
Tag New Review Cycle            : 
Has XFA                         : No
Language                        : EN-US
Tagged PDF                      : Yes
XMP Toolkit                     : Adobe XMP Core 5.4-c006 80.159825, 2016/09/16-03:31:08
Metadata Date                   : 2018:01:18 14:30:19-09:00
Creator Tool                    : Acrobat PDFMaker 11 for Word
Document ID                     : uuid:ae377906-85ba-4392-831f-f5742b0aed6c
Instance ID                     : uuid:f8370f96-d440-468b-86fd-1b65ffd59d98
Format                          : application/pdf
Title                           : License application
Description                     : 
Creator                         : Debbie Smith
Producer                        : Adobe PDF Library 11.0
Keywords                        : 
State                           : 1
Version                         : 1.1
Page Layout                     : OneColumn
Page Count                      : 1
EXIF Metadata provided by EXIF.tools

Navigation menu