Fill - Free fillable 4317 Form 4317 - Mail-in Driver License Application PDF form

You may qualify to renew your driver license or obtain a duplicate driver license if you are active duty military personnel or dependent and are temporarily out-of-state or

country. Please complete this application and submit the required documents in order to receive a Missouri driver license through the mail.

Must be completed by applicant

In the past 6 months have you had:

Convulsions, Epilepsy or Blackouts r Yes r No

Paralysis r Yes r No

Heart Attack, Stroke, Heart Disease r Yes r No

Other (If yes, please explain) r Yes r No

Last Name First Name Middle Name Suffix Sex Missouri Driver License Number

Missouri Street Address (No PO Boxes) *Required Field City State ZIP Code County

Out-of-State or Country Mailing Address * Required Field City State or Country ZIP Code When will you return to Missouri?

Mail-to Address E-mail Address

Last 4 Digits of Date of Birth Place of Birth (Optional) Height Weight Eye Color Telephone Number Select One

Social Security Number

Select the type of license you currently hold. (Select only one) *Required Field Do you understand that any other driver license in your name is invalid with this application?

Office Use Only

Complete both sides of this application and answer all questions that apply to you.

r Renewal

r Duplicate

Physical Signature Only

I hereby certify under penalty of perjury, that all information regarding this transaction,

including my residential address furnished pursuant to Sections 302.171 and 302.181

RSMo is true and accurate. (Signature must be centered in the box and not extend

outside the box.)

Military

Military Dependent

Class A

Class B

Class C

Class E

Class F

Class M

r Check r Money Order r Credit Card

If you are paying by credit card you must include the following:

Card type:

r Discover r Mastercard r American Express r Visa

Card Number: ____________________________________________

Name on Card: ___________________________________________

Expiration Date: (MM/YY) __ __ / __ __

A convenience fee will be charged for credit or debit card transactions.

Yes

Any license, permit or identication card issued in any other U.S.

jurisdiction will also be invalid with this application.

r Out of State r Out of Country r Missouri

Male

Female

Signature Box

Form

4317

Mail-in Driver License Application

Any person applying for a commercial driver license (CDL) must certify to one of the four categories shown below in the Self-Certification Information block indicating the

type of commercial vehicle operation they drive in or expect to drive in with their CDL.

Drivers who select “non-excepted interstate” or non-excepted intrastate” below must also submit a current medical examiner’s certificate, and any applicable waivers, with

this form.

I certify my commercial operating status is-check only one box below:

(Selecting more than one box will delay processing of this form.)

r Non-excepted Interstate - (NI) Operates or expects to operate in interstate commerce

and is subject to and meets the qualification requirements under 49 CFR part 391, and

is required to obtain a medical examiner’s certificate by 49 CFR 391.45. (Current medical

examiner’s certificate, and any applicable waiver, must be submitted with this form.

r Non-excepted Intrastate - (NA) Operates only in intrastate commerce and is required

to meet Missouri’s current medical requirements. (Current medical examiner’s

certificate, and any applicable waiver, must be submitted with this form.)

r Excepted Interstate - (EI) Operates or expects to operate in interstate commerce,

but engages exclusively in transportation or operations excepted under 49 CFR

390.3(f), 391.2, 391.68, or 398.3 from all or parts of the qualification requirements

certificate by 49 CFR 391.45. These exceptions are listed in detail on the Department

of Revenue’s website at dor.mo.gov/faq/drivers/medcert.php.

r Excepted Intrastate - (EA) Operates or expects to operate in intrastate

commerce, but engages exclusively in transportation or operations that

are excepted from all parts of Missouri’s medical requirements. (This is

Missouri’s grandfather exemption where the driver operates solely in

intrastate commerce and had a valid chauffeur’s license on or before

May 13, 1988.)

Have you been licensed in any other state within the past 10 years?

r Yes r No

If yes, please submit a list of those states, your license number, if known,

and any alias names that you may have used while licensed in that state.

Commercial Driver License Only

Voter RegistrationAppropriate License Fee

Applicant’s Signature *Required

Medical

Are you registered to vote at your current address? r Yes r No Do you wish to register to vote? r Yes r No

The office where the registration application was submitted and your decision of whether or not to register will remain confidential and will be used for voter registration

purposes only.

All information provided on this mail in application form will be used for voter registration purposes, unless you opt out. r Opt-Out

The address change you submitted will be used to update your voter registration information unless you opt out by checking this box. r Opt-Out

Your signature in this section serves as an attestation under penalty of perjury that all of the following requirements have been met:

1. I am a U.S. Citizen. 5. I am not conned under a sentence of imprisonment.

2. I am a Missouri resident. 6. I am not on probation or parole after conviction of a felony, until nally discharged.

3. I am at least 17 1/2 years of age (must be 18 to vote). 7. I have not been convicted of a felony or misdemeanor connected with the right to suffrage.

4. I have not been adjudged incapacitated by a court of law.

I swear under penalty of perjury that all statements made on this card are true to the best of my knowledge and belief. I understand that if I register to vote knowing that

I am not legally entitled to register, I am committing a class one election offense and may be punished by imprisonment of not more than ve years or by a ne between

$2,500 and $10,000 or by both such imprisonment and ne.

Signature __________________________________________________________ Date ____________________________

Reset Form

Print Form

r Proof of Military Active Duty or Dependent Status (such as photocopy of active duty military or military dependent photo ID , military orders or other documentation

of current military status) - Required for ALL applicants. Note: The vision examination and highway sign recognition test are waived upon proof of status.

r Proof of Identity, Lawful Status, Social Security Number, Residence Address and Legal Name Change (if applicable) - You must submit one or more documents from

each of the dened categories in the acceptable documents list attached. Application for a renewal or duplicate non REAL ID-compliant card requires submission of proof of

identity, proof of Missouri residence address and proof of mailing address. Name change verication may be required if the name on the application differs from the name on

your current Missouri license. Application for a renewal or duplicate REAL ID-compliant card (has star marking) requires submission of proof of: identity, lawful status, Social

Security Number, Missouri residence address (2 documents), mailing address and name change if applicable. Acceptable document lists for a REAL ID-compliant or non REAL

ID-compliant card may also be found on-line at www.dor.mo.gov.

r Appropriate License Fee - Required for all applicants. Payment may be made by a U.S. cashier’s check, money order, traveler’s check, personal check or credit card. Make

check or money order payable to Missouri Department of Revenue. If payment is to be made by credit card complete the credit card information section within the application

form. NOTE: If your driver license is within six months of expiring when the mail-in application is received in our office, the transaction is processed as a renewal.

• Renewal driver license (Age 21-69) Class F or M = $27.00 Class E = $42.00 Class A, B, or C = $52.00

• Renewal driver license (All other ages) Class F or M = $13.50 Class E = $21.00 Class A, B, or C = $26.00

• Duplicate of a 6-year driver license Class F or M = $19.50 Class E = $27.00 Class A, B, or C = $32.00

• Duplicate of a 3-year driver license Class F or M = $13.50 Class E = $21.00 Class A, B, or C = $26.00

(Under 21 or 70 and older)

Please be sure to write your driver license number on your check or money order. If you have marked on the application that you would like to donate to either or both of the

funds, you must add that donation to your fee.

A convenience fee will be charged for credit or debit card transactions.

r Signed Application Form - Complete all parts of this application and review prior to signing. Your physical signature must appear within the signature box on the opposite

page. Digital signatures are not accepted.

r Permanent Disability Indicator - If you are permanently disabled, you may apply for a permanent disability indicator indicating such status to be placed on the back of your

driver or nondriver license. To have the indicator added to your document, you must submit a Physician’s Statement - Permanent Disability Indicator (Form 5294). If your current

license has a permanent disability indicator, you may elect to retain the indicator on your new or renewal document. A new physician’s statement is not required.

r DHH Indicator - If you are deaf or hard of hearing you may ask when applying or renewing your driver license, nondriver license, or instruction permit for the “DHH” notation

to be placed on your driver license, nondriver license, or instruction permit. In the event of an emergency this notation will allow law enforcement or emergency and medical

personnel to readily determine if you are deaf or hard of hearing. This will assist in ensuring effective communications with someone who is injured and non responsive. In order

to obtain the “DHH” notation, you must request the notation when applying for a license or instruction permit.

r Boater Identification Indicator - If you have been issued a boating safety education card by the Missouri State Water Patrol under Section 306.127, RSMo, you may elect to

have a boater identification indicator placed on the back of your driver license. To have the indicator added to your document, you must submit the control number from your

Boating Safety Education Card and add an additional $1.00 to your transaction.

If your current license has a boater identification indicator, you may elect to retain the indicator on your new or renewal document. There is no additional cost to retain a

previously issued indicator.

r Veteran Indicator - Applicants requesting the “VETERAN” designation must submit one of the following documents to verify veteran status at the time of initial request for

the driver or nondriver license with the new designation: a U.S. Department of Defense discharge document, otherwise known as a DD Form 214, that shows a discharge

status of “honorable” or “general under honorable conditions” that establishes the person’s service in the Armed Forces of the United States; a U.S. Uniformed

Services Identification Card, otherwise known as a DD Form 2, that includes a discharge status of “retired” or “reserve retired” establishing the person’s service

in the Armed Forces of the United States; a U.S. Department of Veterans Affairs photo identification card; or a discharge document WD AGO 53, WD AGO 55, WD AGO 53-55,

NAVPERS 553, NAVMC 78 PD, NAVCG 553, or DD 215 form that shows a discharge status of “honorable” or “general under honorable conditions”.

r Organ Donor Indicator - You are under no obligation to sign up to be an organ and tissue donor. Your response regarding organ and tissue donor status may be shared

directly with the Local Election Authority of the applicant’s county in accordance with the National Voters Registration Act. Your decision to become an organ and tissue donor

is a private one, so an applicant may register privately at www.MissouriOrganDonor.com.

Mail-in Driver License Application and Instructions (Active Duty Military Personnel and Military Dependents Only)

Please read all instructions before completing the form. Your mail-in license application will be processed within 7-10 days from the date it is received in our office.

This form is not for use by Missouri drivers who are currently in the State of Missouri.

This form is also not valid to renew or replace a “valid without photo” (VWP) driver license, except for active duty U.S. military personnel. REAL ID Information

* Requests for issuance of an initial REAL ID-compliant document must be completed in person.

* You may be issued a REAL ID-compliant license by mail if your current license was issued in-person and you were issued a REAL ID-compliant card.

Incomplete applications will not be accepted. You must submit the following:

The completed and signed application form, along with all required supporting documents required may be submitted by mail, fax or may be scanned and sent via email.

Applications submitted without the required supporting documents will not be processed.

DHH

Are you deaf or hard of hearing, and wish to add the

“DHH” notation to your driver license?

r Yes r No

Organ Donor

Please refer to www.MissouriOrganDonor.com regarding the First Person Consent Organ,

Eye, and Tissue donor registry prior to answering the following questions.

Do you want to donate $1.00 to the organ donor fund?

r Yes r No

Do you consent to be listed in the Donor Registry System as an organ,

eye and tissue donor?

r Yes r No

Do you authorize the Organ Donor symbol to be placed on your license

or permit?

r Yes r No

License Indicators & Notations

Boater Identification

Do you wish to add or retain a boater identification indicator to your driver license? r Yes

Boating Safety Education Control Number _______________

Veteran

Do you wish to add or retain a Veteran indicator on your driver license? r Yes

If yes, acceptable discharge document must be submitted.

Blindness Awareness Fund

Do you want to donate $1.00 to the Blindness

Awareness Fund?

r Yes r No

Selective Service (Male applicants age 18-26 years of age)

Do you wish to register with the Selective Service? r Yes r No

Permanent Disability

Do you wish to add or retain a permanent disability

indicator to your driver license?

r Yes r No

Mail to: Driver License Bureau Phone: (573) 526-2407

Attention MIL Fax: (573) 522-8174

P.O. Box 200 E-mail: dlbmail@dor.mo.gov

Jefferson City, MO 65105-0200

Visit http://www.dor.mo.gov/drivers/

for additional information.

Form 4317 (Revised 01-2020)

1. Identity

One (1) of these documents with your full name and

date of birth:

r Valid, Unexpired U.S. passport

r Valid, Unexpired U.S. passport card

r Certied U.S. Birth Certicate

r U.S. Birth Abroad

r Certicate of Naturalization

r Certicate of Citizenship

r Valid, Unexpired Permanent Resident Card

r Valid Foreign Passport stamped approved

or processed for an I-551

r Valid, Unexpired Arrival/Departure Record

r I-94 with “Temporary I-551” stamp

r Valid, Unexpired Employment Authorization Document (EAD)

r Valid, Unexpired Foreign Passport with a valid, unexpired US

visa accompanied by an I-94

r Valid, Unexpired Out of State Real ID driver’s license, permit

or identication card

r Valid, Unexpired Missouri Real ID driver’s license, permit or

identication card

2. Lawful Status

One (1) of these documents with your full name and date of birth:

r Valid, Unexpired U.S. passport

r Valid, Unexpired U.S. passport card

r Certied U.S. Birth Certicate

r U.S. Birth Abroad

r Certicate of Naturalization

r Certicate of Citizenship

r Valid, Unexpired Permanent Resident Card

r Valid, Unexpired Employment Authorization Document (EAD)

r Valid, Unexpired Foreign Passport with a valid, unexpired U.S.

visa accompanied by an I-94

The following documents are not acceptable as a primary lawful

status document for REAL ID-Compliant document issuance,

however, they may be required as a secondary document to

complete required status verications.

r Valid, Unexpired Visa with temporary

r I-551 language

r Valid, Unexpired I-551 Stamp on I-94 or Passport

r I-20 Non-immigrant Student Certicate

r DS2019 Exchange Visitor Certicate

r I-94 – Arrival/Departure record

r I-327 Reentry Permit

r I-571 Refugee Travel Document

r I-589 Proof of Application for Asylum in the U.S.

r I-797 Approval Notice of Action

r Unexpired Foreign Passport from Micronesia accompanied

by an I-94 with code CFA/FSM

r Unexpired Foreign Passport from Palau accompanied by

an I-94 with code CFA/PAL

r Unexpired Foreign Passport from Marshall Islands

accompanied by an I-94 with code CFA/MIS or CFA/RMI

3. Social Security Number

Document must contain your name and full Social Security

Number (SSN), must be signed and may not be laminated or

altered in any way:

r Social Security Card (must be signed)

r W-2 Form

r SSA-1099 Form

r Non-SSA-1099 Form

r Pay Stub with applicant’s name and SSN

r No Social Security Number verication letter from the Social

Security Administration

(Only acceptable when submitted with an Unexpired Foreign

Passport with a valid, unexpired U.S. visa accompanied by an I-94)

4. Proof of Missouri Residency

Document must include name and residence address. Document

 mustbethemostrecentlyissuedversion,unlessotherwisespecied,

and should be presented in paper format. If you have an alternate

mailing address an additional document from this list must be

presented to verify the mailing address.

r Utility Bill (Phone, Water, Gas, Electric, Trash or Sewer, Etc.)

r Voter Registration Card

r Bank Statement (Credit Union, Credit Card, Investment)

r Government Check or Pay Check

r Property Tax Receipt

r Mortgage, Housing, or Leasing Document

r Homeowner’s Insurance Policy

r Auto Insurance Policy or card

r W-2

r 1099 Form

r Safe At Home Card

r Driver License Renewal Post Card

r Motor Vehicle Renewal Post Card

r Education Transcript for current school year from an educational

institution in Missouri

r Professional License (Nurse, Physician, Engineer, Etc.), Only If

Home Address

r Real Estate tax receipt, Only If Primary Residence Address

r Letter from Shelter (homeless only, not acceptable for CDL or CLP)

r Ofcial letter or document from another State or local Government

agency (on agency letterhead OR which contains the ofcial seal of

the Agency) issued within the previous 30 days

r Letter or other documentation issued by the Postmaster within the

previous 30 days

r Other Government document containing the name and address of

the applicant issued within the previous 30 days

In addition to the above, applicants under the age of 21 may also present:

r Missouri School Records

r Hospital or Medical Record

r Mailed Correspondence issued by an Organization such as Boy

Scouts of America, Girl Scouts of America;

r Missouri Department of Conservation or other well established

organizations or programs containing the name and address of the

applicant

For persons under 21 years of age only, a parent or legal guardian may

provide a document in their name and address and a statement that the

applicant resides in their household.

5. Name Change

Required if applicable to verify current full legal name or requested

name change. More than one may be required to verify connection

to identity and lawful status document presented.

r Certied Marriage License

r Certied Divorce Decree

r Certied Adoption Papers

r Amended Birth Certicate

r Other Certied Court Order

Acceptable Documents

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4317 Form 4317 - Mail-in Driver License Application

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