DMV USE ONLY APPLICATION FOR A NON-COMMERCIAL …

1 DMV USE ONLYNEWOUT OF STATETRANSFERRETESTCHANGE ENDORSEMENT/RESTRICTIONEXCHANGEAPPLICATI ON FOR A NON-COMMERCIALLEARNER PERMIT AND/OR DRIVER LICENSE R-229 REV. 7-2013 STATE OF CONNECTICUTDEPARTMENT OF MOTOR VEHICLESOn The Web At PERMIT NUMBERDATE OF ISSUEAPPLICANT'S NAME (Last, First, Middle, Suffix)2. SEX3. DATE OF BIRTH4. HEIGHT5. COLOR OF ADDRESS (No., Street, City or Town, State, Zip Code)7. RESIDENCE ADDRESS (If different)12. LIST ANY OTHER NAMES EVER USED (Alias, Maiden, etc)QUESTIONSYES ( ) NO ( )Have you previously failed a driver's licenseexamination in Connecticut?Do you now hold or have you ever held an operator's license oridentification card from another state? , DRIVER LICENSE OR ID. OF YEARSIN WHAT STATE(S)?Do you now, or have you ever held a Connecticut Learner Permit,License or Non-Driver Identification card?

2 IF YES, IN WHAT YEAR(S)?CONNECTICUT PERMIT, LICENSE OR ID NO. (9 digits)MEDICALCERTIFICATIONI hereby certify that I do nothave any health or visionproblems or conditions thatprevent me from driving NOT WRITE BELOW THIS LINE - OFFICE USE ONLYPROOF OFIDENTIFICATIONTYPE OF ACCEPTABLE SHOWNThe information provided to the Commissioner of Motor Vehicles herein issubscribed by me, under penalty of false statement, in accordance withthe provisions of Section 14-110 and 53a-157b of the Connecticut GeneralStatutes. I understand that if I make a statement which I do not believe tobe true, with the intent to mislead the Commissioner, I will be subject toprosecution under the above-cited OF APPLICANTXDATE SIGNEDVISIONSCREENINGRESULTSVISUAL AID USEDNONEGLASSES/CONTACTSRESULTSPASSEDFAI LEDKNOWLEDGETESTCOMPUTERWRITTENORALTEST RESULTSWAIVEDPASSEDFAILED PERMITISSUE MOTORCYCLE PERMITAGENTCERTIFICATIONI hereby certify that I have examined the applicant's identitydocuments and the test results stated herein are true (Agent)DATE SIGNEDXCLASSROOMINSTRUCTIONSCHOOL NAMECOMMERCIAL SCHOOL LICENSE EDUCATION CERTIFICATE NAME (If same as above print "same")

3 COMMERCIAL SCHOOL LICENSE EDUCATION CERTIFICATE hereby subscribe and certify under penalty of false statement, in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes that Iunderstand that if I make a statement, which I do not believe to be true, with the intent to mislead the Commissioner I will be subject to prosecution under the above-cited laws, that,I am qualified under Section 14-36, of the Connecticut General Statutes, over 20 years of age, have no suspensions within the previous 4 years and the Applicant has received therequired training, including the equivalent of 22 hours classroom training; 40 hours on-the-road instruction; the 8 hours Safe Driver course, including a 2 hour Parent Training, assupported by a parent log and/or driving school OF INSTRUCTOR (Home Training/Commercial)XROAD TEST AND LICENSEINFORMATIONWAIVEDPASSEDFAILEDNO EQUIPMENTNON-COMMERCIAL CLASSENDORSEMENTRESTRICTIONS (Circle All Applicable)DMQBCDEFGRUI hereby certify that I have verified the applicant'sidentity and the test results stated herein are trueand : White - Branch Office Canary - Agent Pink - ExaminerSIGNED (Agent)DATE CITIZEN?

4 "NO", list ALIEN REGISTRATION YOU WANT TO BE IN THE ORGAN/TISSUE DONORREGISTRY?YesNoIf yes, you are agreeing to be a donorand the designation will be on PHONE NO.( )Is your privilege to operate a motor vehicle suspended or subject tosuspension in Connecticut or in any other state?1 Home Training22 hr class equiv40 hr on-the-road8 hr safe driving2 Comm/Sec and Home30 hrs class/minimum8 hr safe driving plus hometraining 40 hrs on-the-road3 Comm/Sec Only30 hrs class40 hrs on-the-roadLOCATION/DATEOPERATOR LICENSE NUMBER ORSCHOOL LICENSE SCANNED FIRST VISITEXAMINER INITIALSTAMP NO. AND PUNCHAGENTCERTIFICATIONPUNCH NO. AND PUNCHR equired Identification Documents & Proof of ConnecticutResidency: see "Acceptable Forms of ID" at and 17 year olds: Certificate of Parental Consent Form 2D(if not accompanied by authorized individual)Applicable FeesKNOWLEDGEVISIONROAD SKILLSCERTIFICATIONBY APPLICANTPARENTALCONSENTAGE 16 OR 17 ONLYI hereby request that a learner's permitand/or license be issued to the minorfiling this TO MINORSIGNED (Authorized Consenter)CONSENTER'S LIC.

5 NO. OR OTHER LEARNER PERMITAGENTS INITIALSPUNCH NO. AND PUNCHINSTRUCTIONS: Complete 1-16, then SOCIAL SECURITY LEGALNAMEIf different than entered in name section above (# 1)IDENTIFICATION DOCUMENTSRETURNEDAPPLICANT INITIALSISSUE PERMIT WITH CORRECTIVE LENSES(B-RESTRICTION)Section 14-36l of the Connecticut General Statutes requires the Commissioner to transmit myinformation to the Selective Service System. By signing and submitting this APPLICATION , I consentto be registered with the Selective Service System, provided I am at least age 16 but under age26 and meet the criteria for registration in accordance with the Military Selective Service Act. If Iam under age 18, I understand that my information will be transmitted to Selective Service but Iwill not be registered until I reach age USE ONLYNEWOUT OF STATETRANSFERRETESTCHANGE ENDORSEMENT/RESTRICTIONEXCHANGEAPPLICATI ON FOR A NON-COMMERCIALLEARNER PERMIT AND/OR DRIVER LICENSE R-229 REV.

6 7-2013 STATE OF CONNECTICUTDEPARTMENT OF MOTOR VEHICLESOn The Web At PERMIT NUMBERDATE OF ISSUEAPPLICANT'S NAME (Last, First, Middle, Suffix)2. SEX3. DATE OF BIRTH4. HEIGHT5. COLOR OF ADDRESS (No., Street, City or Town, State, Zip Code)7. RESIDENCE ADDRESS (If different)12. LIST ANY OTHER NAMES EVER USED (Alias, Maiden, etc)QUESTIONSYES ( ) NO ( )Have you previously failed a driver's licenseexamination in Connecticut?Do you now hold or have you ever held an operator's license oridentification card from another state? , DRIVER LICENSE OR ID. OF YEARSIN WHAT STATE(S)?Do you now, or have you ever held a Connecticut Learner Permit,License or Non-Driver Identification card?IF YES, IN WHAT YEAR(S)?CONNECTICUT PERMIT, LICENSE OR ID NO. (9 digits)MEDICALCERTIFICATIONI hereby certify that I do nothave any health or visionproblems or conditions thatprevent me from driving NOT WRITE BELOW THIS LINE - OFFICE USE ONLYPROOF OFIDENTIFICATIONTYPE OF ACCEPTABLE SHOWNThe information provided to the Commissioner of Motor Vehicles herein issubscribed by me, under penalty of false statement, in accordance withthe provisions of Section 14-110 and 53a-157b of the Connecticut GeneralStatutes.

7 I understand that if I make a statement which I do not believe tobe true, with the intent to mislead the Commissioner, I will be subject toprosecution under the above-cited OF APPLICANTXDATE SIGNEDVISIONSCREENINGRESULTSVISUAL AID USEDNONEGLASSES/CONTACTSRESULTSPASSEDFAI LEDKNOWLEDGETESTCOMPUTERWRITTENORALTEST RESULTSWAIVEDPASSEDFAILED PERMITISSUE MOTORCYCLE PERMITAGENTCERTIFICATIONI hereby certify that I have examined the applicant's identitydocuments and the test results stated herein are true (Agent)DATE SIGNEDXCLASSROOMINSTRUCTIONSCHOOL NAMECOMMERCIAL SCHOOL LICENSE EDUCATION CERTIFICATE NAME (If same as above print "same")COMMERCIAL SCHOOL LICENSE EDUCATION CERTIFICATE hereby subscribe and certify under penalty of false statement, in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes that Iunderstand that if I make a statement, which I do not believe to be true, with the intent to mislead the Commissioner I will be subject to prosecution under the above-cited laws, that,I am qualified under Section 14-36, of the Connecticut General Statutes, over 20 years of age, have no suspensions within the previous 4 years and the Applicant has received therequired training, including the equivalent of 22 hours classroom training; 40 hours on-the-road instruction.

8 The 8 hours Safe Driver course, including a 2 hour Parent Training, assupported by a parent log and/or driving school OF INSTRUCTOR (Home Training/Commercial)XROAD TEST AND LICENSEINFORMATIONWAIVEDPASSEDFAILEDNO EQUIPMENTNON-COMMERCIAL CLASSENDORSEMENTRESTRICTIONS (Circle All Applicable)DMQBCDEFGRUI hereby certify that I have verified the applicant'sidentity and the test results stated herein are trueand : White - Branch Office Canary - Agent Pink - ExaminerSIGNED (Agent)DATE CITIZEN? "NO", list ALIEN REGISTRATION YOU WANT TO BE IN THE ORGAN/TISSUE DONORREGISTRY?YesNoIf yes, you are agreeing to be a donorand the designation will be on PHONE NO.( )Is your privilege to operate a motor vehicle suspended or subject tosuspension in Connecticut or in any other state?

9 1 Home Training22 hr class equiv40 hr on-the-road8 hr safe driving2 Comm/Sec and Home30 hrs class/minimum8 hr safe driving plus hometraining 40 hrs on-the-road3 Comm/Sec Only30 hrs class40 hrs on-the-roadLOCATION/DATEOPERATOR LICENSE NUMBER ORSCHOOL LICENSE SCANNED FIRST VISITEXAMINER INITIALSTAMP NO. AND PUNCHAGENTCERTIFICATIONPUNCH NO. AND PUNCHR equired Identification Documents & Proof of ConnecticutResidency: see "Acceptable Forms of ID" at and 17 year olds: Certificate of Parental Consent Form 2D(if not accompanied by authorized individual)Applicable FeesKNOWLEDGEVISIONROAD SKILLSCERTIFICATIONBY APPLICANTPARENTALCONSENTAGE 16 OR 17 ONLYI hereby request that a learner's permitand/or license be issued to the minorfiling this TO MINORSIGNED (Authorized Consenter)CONSENTER'S LIC. NO. OR OTHER LEARNER PERMITAGENTS INITIALSPUNCH NO.

10 AND PUNCHINSTRUCTIONS: Complete 1-16, then LEGALNAMEIf different than entered in name section above (# 1)IDENTIFICATION DOCUMENTSRETURNEDAPPLICANT INITIALSISSUE PERMIT WITH CORRECTIVE LENSES(B-RESTRICTION)Section 14-36l of the Connecticut General Statutes requires the Commissioner to transmit myinformation to the Selective Service System. By signing and submitting this APPLICATION , I consentto be registered with the Selective Service System, provided I am at least age 16 but under age26 and meet the criteria for registration in accordance with the Military Selective Service Act. If Iam under age 18, I understand that my information will be transmitted to Selective Service but Iwill not be registered until I reach age