License Application 478
User Manual: 478
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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
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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 : 1EXIF Metadata provided by EXIF.tools