LAST NAME (PRINT NAME)
CLASS C
INSTRUCTION PERMIT
DRIVER LICENSE
ENDORSEMENT
ID CARD AT-RISK
FT. IN.
M F X
Do you want your license or ID card to show
that you are an anatomical donor?
LBS.
APPLICANT’S PLACE OF BIRTH (CITY & STATE OR COUNTRY)
MOTHER'S MAIDEN NAME
FIRST NAME
DRIVER / ID NUMBER
RESTRICTIONS
HEIGHT WEIGHT
SEX
(CIRCLE)
EYE COLORHAIR COLOR
RESIDENCE ADDRESS
CITY, STATE, ZIP CODE
MAILING ADDRESS (IF DIFFERENT FROM RESIDENCE ADDRESS)
CITY, STATE, ZIP CODE
NO
YES
APPLICATION FOR DRIVING PRIVILEGES OR ID CARD
735-173 (1-20)
DATE STAMP
STK# 300093
TSR ID
You are required to report any mental or physical condition or impairment that affects your ability to drive safely. You are not required to report all your
health conditions – only those that affect your ability to drive safely. DMV will use your answers to the following questions only for the purpose
of determining your eligibility for an Oregon driving privilege. If you have a condition or impairment that makes you unable to safely operate a motor
vehicle, you are not eligible for a driving privilege until you have provided additional medical information and/or passed DMV tests. If you answer “Yes”
to any one of the questions below, we will not be able to issue you a license at this time.
2. Do you have any physical or mental conditions or impairments that affect your ability to drive safely?
*
If Yes: a) What is the condition or impairment?: ___________________________________________________________________________________
Describe how this affects your ability to drive safely: ________________________________________________________________________
3. Do you use alcohol, inhalants, or controlled substances to a degree that affects your ability to drive safely?
*
IfYes: Describe how your use affects your ability to drive safely:_________________________________________________BB___________________
YES
NO
YES*
NO
DATE
YES* NO
DRIVE TEST
STOP - DO NOT WRITE IN THE AREA BELOW - FOR DMV OFFICE USE ONLY
TSR IDDATE
VISION:
OK W/BIOPTIC LENSES
OK/WCL
OK
OUTSTANDING REQUIREMENTS
DATE RECEIVED
TSR ID
VISION
DATE STAMP TEST
TEST
TEST
SCORE
SCORE
SCORE
TSR ID
TSR ID
TSR ID
DATE STAMP
DATE STAMP
KNOWLEDGE TEST
2
DATE CLASS SCORE TSR ID
3
DATE CLASS SCORE TSR ID
1
DATE CLASS SCORE TSR ID
X
DOCUMENTS PRESENTED
DATE DATE2nd CHECKTSR ID 2nd CHECKTSR ID 2nd CHECKTSR ID
$
FEE
DATE OF BIRTH (M-D-Y)
US BIRTH CERTIFICATE/PASSPORT/PASSPORT CARD
FOREIGN PASSPORT & DHS DOC. or ADMIT. STAMP
DHS DOCUMENT
OTHER (Specify) _________________________
LP=C LP=P LP=F LP=U
CURRENT OR PREVIOUS MILITARY SERVICE: By checking this box I authorize DMV to send my name and address to the
Oregon Department of Veterans' Affairs (ODVA) for the purpose of receiving benefit information.
MC
ORIGINAL RENEWAL REPLACEMENT
REFERRED:
DOCUMENTS PRESENTED
US BIRTH CERTIFICATE/PASSPORT/PASSPORT CARD
FOREIGN PASSPORT & DHS DOC. or ADMIT. STAMP
DHS DOCUMENT
OTHER (Specify) _________________________
LP=C LP=P LP=F LP=U
DOCUMENTS PRESENTED
US BIRTH CERTIFICATE/PASSPORT/PASSPORT CARD
FOREIGN PASSPORT & DHS DOC. or ADMIT. STAMP
DHS DOCUMENT
OTHER (Specify) _________________________
LP=C LP=P LP=F LP=U
By signing this application, I certify that all documentation and information I provided to DMV is true and correct. I understand it is a crime to knowingly
make a false application for driving privileges or ID card. The offense is a class A misdemeanor and is punishable by jail time, a fine or both. DMV
will cancel and/or suspend my permit, driver license or ID if I make a false statement or present false documentation.
X
SIGNATURE OF APPLICANT
SSN:
Disclosure of your Social Security number (SSN) is mandatory for issuance, renewal or replacement of your driver license or identification card under ORS 807.021(1).
UNDER
18 years
of age:
I am a resident of or
domiciled in Oregon
as described in ORS
807.062
Signature of applicant’s mother or father whose parental rights have not been terminated or legal guardian as
required by ORS 807.060(2). If applying for first driving privilege, applicant meets
school enrollment
requirements under ORS 807.066 or has a diploma or GED (proof of diploma or GED required). If applying
for first Class C license, applicanthas completed driving experience requirements under ORS 807.065(1)(2):
50 hours and Driver Education or100 hours, or has a valid license from another state.
MC-3
MOTORCYCLE
ASS C RESTR'D
LP or ADDRESS
REIN. FEE/SR-22
OTHER:
NOTE:
FARM
MIDDLE NAME
SOCIAL SECURITY NUMBER
9RWHUUHJLVWUDWLRQIRUPVDUHDYDLODEOHDWWKH'09RIILFH,I\RXZRXOGOLNHWRUHJLVWHUWRYRWHWRGD\SOHDVHDVND'09FOHUN
DM V
1.
Have you ever had a driver license from another state, U.S. territory, or country?
YES
3.
APPLICANT INFORMATION:
NOTE: YOUR ADDRESS BELOW MUST BE CURRENT. THE U.S. POSTAL SERVICE WILL NOT FORWARD YOUR LICENSE OR ID CARD.
DRIVING HISTORY:
1.
TELEPHONE NUMBER
( )
APPLICANT CERTIFICATION
:
MEDICAL FITNESS: Skip this section if applying for an Identification Card.
2. Is your driver license currently suspended, cancelled or revoked?
If yes, what state or country: ____________ Number (if known):
__________
List other names you have used on a driver license or ID card.
1. __________________________________ 2.
__________________________________
NO
YES
NO
G
DAYLIGHT
ACUITY F.O.V.
DRIVING ONLY
F
OUTSIDE
MIRROR
TSR ID
SIGNATURE OF MOTHER, FATHER, OR LEGAL GUARDIAN
