License Application 478
User Manual: 478
Open the PDF directly: View PDF 
.
Page Count: 1
STATE OF ALASKA
DIVISION
OF M
OTOR
VEHICLES
APPLICATION FOR ALASKA DRIVER LICENSE,
PERMIT OR IDENTIFICATION CARD
(Rev.08/14/2017) Alaska.gov/dmv
FULL
LEGAL
NAME:
First Middle Last Suffix
AK license / permit / ID number, if applicable. Date of Birth Sex Height
ft in
Weight Hair Color Eye Color
PLACE
OF
BIRTH:
City State 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 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
ORGAN DONOR
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?
$
VOTER
REGISTRATION
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
Have you been unconditionally discharged?
YES NO
Would you like your residence address kept confidential? (Your residence address must be DIFFERENT than your mailing
address to be kept confidential.)
YES NO
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
PREVIOUS
NAMES
List any previous / maiden names by which you have been known:
DRIVER
LICENSE
QUESTIONS
(You do not need to
answer these
questions for an ID
card)
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?
YES NO
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
If yes, please explain:
Within the last five years, have you had three or more alcohol or drug related convictions?
YES NO
If yes, you must provide physician verification that the problem is under control or proof of completion of a rehabilitative treatment program
COMMERCIAL
DRIVERS ONLY
Are you domiciled (permanent residence) in the State of Alaska? YES NO
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 Vision Notes
CDL Color Blind Test:
LICENSE
Orig Renew Duplicate
Without CL 20/ 20/ 20/
Pass / Fail / Medical Card
ISSUED
Class:
DOCUMENTS SEEN / OTHER NOTES
478
LICENSE / PERMIT CLASSIFICATION ENDORSEMENTS
Driver License
Non-Commercial (D)
Hazardous
Passenger (P)
Instruction Permit
Motorcycle
Tank (N)
School Bus (S)
Identification Card
CDL A B C
Tank (N) + HazMat (H)
Doubles / Triples
