Transcription of DRIVER'S LICENSE AND IDENTIFICATION CARD …
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DRIVER'S LICENSE AND IDENTIFICATION CARD …
NOTE: YOUR address BELOW MUST BE CURRENT. THE POSTAL SERVICE WILL NOT FORWARD YOUR LICENSE OR ID NUMBER (optional)GENDER (check one) FEMALEMALEWEIGHT OF CITY OR COUNTY OF RESIDENCE COUNTY OFCITYSOCIAL SECURITY NUMBER (SSN)BIRTHDATE (mm/dd/yyyy)FULL LEGAL NAME (last, first, middle, suffix)EYE COLORHAIR COLORIF YOUR NAME HAS CHANGED, PRINT YOUR FORMER NAME HERE APPLICANT INFORMATIONSTREET address APT NO. CITY STATE ZIP CODEHEIGHT FT. address (if different from above - this address will show on your LICENSE /permit/ID) APT NO. CITY STATE ZIP CODESPECIAL INDICATOR REQUESTP lease show the following indicator(s) on my LICENSE , permit, or ID card :Must submit required physician statement Insulin-dependent diabeticSpeech impairment Hearing impairment ( LICENSE only)Intellectual disability (IntD)Autism spectrum disorder (ASD)1.
note: your address below must be current. the u.s. postal service will not forward your license or id card. phone number (optional). gender (check one) male. female. weight
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