Fillable APPLICATION FOR ALASKA DRIVER LICENSE, PERMIT OR IDENTIFICATION (State of Alaska)

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APPLICATION FOR ALASKA DRIVER LICENSE, PERMIT OR IDENTIFICATION (State of Alaska)

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STATE OF ALASKA DIVISION
OF M
OTOR
VEHICLES
APPLICATION FOR ALASKA DRIVER LICENSE,
PERMIT OR IDENTIFICATION CARD
Form 478 (revised 12/2019) Page 1
First Name
Middle Name
Last Name
Suffix
Alaska License / Permit / ID Number
Social Security Number (AS 28.15.061)
Date of Birth
Sex
I’m new to Alaska
I have never been assigned a SSN (SSA letter required)
Height
Weight
Eye Color
Where were you born?
ft in lbs
I was born in: (City)
State / Country (if other than US)
Contact Information
Mailing Address
(This is where the card will be mailed)
City
State
Zip Code
Residence Address
(Physical location where you live)
City
State
Zip Code
Email:
Can we contact you via e-mail?
Yes No
Phone Number:
Please print my residential
address on card:
Yes No
1. Are you a U.S. Citizen? U.S. National
Yes No
2. Would you like to register to vote or make changes to your current voter registration?
Yes No
3. Have you ever been known by different legal name? (If yes, please provide all previous names below):
Yes
No
4. Do you currently hold a license, permit, or ID in another state? (If yes, please provide your current license information):
Yes No
License Number: Federally Compliant (Real ID)
Standard (Not Real ID)
State of Issue:
5. Have you ever held a license, permit, or ID in another state? (If yes, please provide the states below):
Yes No
What are you applying for? Federally Compliant Card (Real ID) Standard Card (Not Real ID)
Type of License / Permit / ID
Optional Designators
Commercial Endorsements
Instruction Permit (IP)
Non-Commercial Driver License (D)
Motorcycle Permit (IM)
Motorcycle License (M1) or (M3)
Identification Card (ID)
Commercial Driver License*: A B C
Commercial Learner’s Permit*: IA IB IC
Other: __________________
*Additional information is required for Commercial applicants on Form 413
Hidden Disability
Proof of eligibility required)
VETERAN (Proof of honorable discharge required)
Organ Donor
I would like to donate $_________ to the
anatomical gift awar
eness fund.
Passenger (P)
School Bus (S)
Doubles / Triples (T)
Hazardous Materials (H)
Tank (N)
HazMat (H) + Tank (N) = (X)
Tell us about your driving history: (Only necessary to complete if you’re applying for a license or permit.)
6. Have your driving privileges ever been suspended or revoked, or has your application ever been denied?
(If yes, please
provide the reason, state, and date of the suspension, revocation, or denial below):
Yes
No
7. Within the past 5 years, have you had a medical condition or impairment, mental or physical disorder, seizure, or any
other serious health problem that could affect your ability to safely operate a motor vehicle? (If yes, please explain below):
Yes No
DO NOT SIGN UNTIL DIRECTED BY A DMV REPRESENTATIVE
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
certify that I understand the options for driver’s license and identification card types available today and have knowingly selected the type indicated on this form. I certify
that other than the credential I am surrendering today, I do not have a driver’s license or Real ID credential in another 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
Date
LDAP / Office Number
Reset Form
STATE OF ALASKA DIVISION
OF M
OTOR
VEHICLES
APPLICATION FOR ALASKA DRIVER LICENSE,
PERMIT OR IDENTIFICATION CARD
Form 478 (revised 12/2019) Page 2
Parent / Guardian Consent for a Minor:
Pursuant to AS 28.15.071, an application for a person under the age of 18 must be signed by a parent or legal guardian. The person who authorizes
issuance of the license or permit is liable for damages caused by the minor when driving a motor vehicle. You may file a written request to cancel the
license or permit.
Parent / Guardian Consent for a Minor applying for a Motorcycle Permit or License requires a separate Form 433M with the consent of both parents.
Full Legal Name of Parent or Legal Guardian
Relationship to Applicant
Mother Father Other
(please specify below):
Parent or Legal Guardian License / ID Number:
State of Issue: Exp Date:
Full Legal Name of Minor:
Type of License or Permit you are giving consent for your minor to obtain:
Instruction Permit (IP) Provisional Driver License (D) Driver License (unrestricted) (D) ATV & Snow Machine License (R)
B
y signing below, I agree to the terms and conditions stated above. If upgrading from a permit to a provisional license, I further certify that the applicant
has had at least 10 hours of driving experience in inclement weather (snow / ice / rain / darkness / etc.) for a total of 40 hours driving experience.
X
Signature of Parent or Legal Guardian (Do not sign until directed to by a DMV representative)
Date
FOR DIVISION USE ONLY
Test scores are valid for one year. All tests must be verified in the testing system. Road test results must be verified in ALVIN.
Form 478a must be attached when an interpreter or reader is used on a test. (CDL/CLP Tests may only use readers in English)
mm/dd/yy GK MC
Alch
Awareness
CDL
GK
Air Brakes
Combination
(Req for IA)
Passenger
School
Bus
Doubles
/ Triples
(A only)
Tank Hazmat Road
Date
License Checks (Initial each after you have verified the information)
Vision Test Results
USPVS PDPS
Left: 20/_____ Both: 20/_____ Right: 20/_____
VLS
SPEXS
Pointer Taken
No OOS Pointer
With Corrective Lenses Without Corrective Lenses
SSOLV
Color Blind Test
(CDL/CLP only)
Pass Fail
Medical Card
OOS Credential Presented: License/Permit ID
Surrendered: Yes
No
VOID Stamped
OOS License Number: ________________ State: _______
Additional Notes/Affidavit
Transaction Type: Original Duplicate Renewal
Reinstatem
ent
New Number Issued: ________________________ (original only)
Card Type:
Federally Compliant Standard
Class Iss
ued: ID IP D M1 IM Other: ________
A B C IA IB IC
Optional Designators Issued
Hidden Disability Veteran Organ Donor
Unable to Add (explain):
____________________________________
Endorsements / Restrictions Issued
END: P S T N H X
RES: 1 2 A B P X Other: _______________
Documents Accepted Batch Information
Primary Fee Amount
Secondary (standard issuance only) Donation Amount
Name Change Payment Type CA CK CC
Proof of SSN: SSOLV Only Batch Number
Proof of Residence Address Batch Date
Other
LDAP / Office
■
■
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APPLICATION FOR ALASKA DRIVER LICENSE, PERMIT OR IDENTIFICATION (State of Alaska)

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Completed 21 January 2021

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