CDL-1 (Rev. 5/2020)
CERTIFICATION
I do solemnly swear, affirm, or certify that I am the person named herein and that the statements on this application are true and correct. I further certify my residence
address is a (select one): ___ single family dwelling, ___ apartment, ___ motel, ___ temporary shelter. I agree to immediately report to the Texas Department of Public Safety
any changes in my medical condition which may affect my ability to safely operate a motor vehicle. I further understand that I am required by law to report any change of
name or address to the Department of Public Safety within thirty days.
X Signature of Applicant _____________________________________________________ Date _________________________
NOTICE: The information on this application is required by the Texas Driver License Act, Texas Transportation Code Chapter 521. Failure to provide the information is cause
for refusal to issue a driver license or identification card, and in some cases, cancellation or withdrawal of driving privileges. False information could also lead to criminal
charges with penalties of a fine up to $4,000.00 and/or jail.
SOCIAL SECURITY NUMBER COLLECTION DISCLOSURE
Disclosure of your social security account number is mandatory for identification card and driver license applicants, but voluntary for election identification certificate
applicants. This information is solicited pursuant to 42 U.S.C. section 405(c)(2)(C)(i), 42 U.S.C. section 666(a)(13)(A), 6 C.F.R. section 37.11(e), 49 C.F.R. section 383.153, Texas
Family Code section 231.302(c)(1), and Texas Transportation Code sections 521.142 and 522.021. The Department will use social security number information for identification
purposes and will only release the number as statutorily authorized by Texas Transportation Code section 521.044.
UNITED STATES SELECTIVE SERVICE
Any male at least 18 but younger than 26 years of age submitting this application consents to registration with the United States Selective Service System. Alternative
options for those who object to conventional military service for religious or other conscientious reasons may be found at: https://www.sss.gov/About/Alternative-Service.
By submitting this application, I am consenting to registration with the United States Selective Service System if my registration is required by federal law.
DO NOT SIGN BELOW UNTIL INSTRUCTED TO DO SO BY NOTARY PUBLIC OR DRIVER LICENSE EMPLOYEE.
Sworn to and subscribed before me this _______________ day of _________________________________________, _____________
Notary Public in and for the State of Texas/Authorized Officer r
8. ___ ___ Are you a veteran? If no, go to question 9.
___ ___ a.) Do you want a Veteran designator on your DL or ID, or
___ ___ b.) Are you 50% disabled or are you 40% and have had a lower extremity amputated and want a Disabled Veteran designator on your DL or ID?
(Proof of honorable discharge required; some acceptable documents are DD214/215, NGB22, VA disability letter, Veteran Identification card,
proof of service/verification of honorable service card. Proof of disability is required for Disabled Veteran designator)
___ ___ c.) If you want a Veteran or Disabled Veteran designator, do you want the branch of service shown on your DL or ID? If yes, select one:
_____ Army _____ Air Force _____ Coast Guard _____ Marines _____ Navy
9. ___ ___ Do you have a health condition that may impede communication with a peace officer? If yes, please list: (Physician must complete form DL-101).
10. ___ ___ Would you like to register as an organ donor?
11. ___ ___ Are you at this time placed out-of-service? Why? _________________________________________________________________________________________
12. ___ ___ Have you ever had a driver license or instruction permit in Texas? Number______________________________ When? _______________________________________
13. ___ ___ Have you ever had a driver license or instruction permit in any other state in the last ten years? If yes, list state and driver license number.
State____________ Number_______________________________________ State____________ Number __________________________________________________________
14. ___ ___ Have you ever had a Texas identification card? Number____________________________________ When? _____________________________________________________
15. ___ ___ Are you enrolled in or have you completed an approved driver education course?
16. ___ ___ Is your driver license or driver privilege CURRENTLY or EVER been suspended, revoked, cancelled, denied or disqualified in ANY state?
State?_____________ When?___________________________ Why? ___________________________________________________________________________________________________
VEHICLE REGISTRATION AND INSURANCE INFORMATION
17. ___ ___ Do you own a motor vehicle that is required to be registered? (Texas Transportation Code section 502.040)
18. ___ ___ Do you own a motor vehicle that is required to have liability insurance OR other proof of financial responsibility in compliance with the Motor
Vehicle Safety Responsibility Act? (Texas Transportation Code section 601.051)
MEDICAL HISTORY
19. ___ ___ Do you currently have or have you ever been diagnosed with or treated for any medical condition that may affect your ability to safely operate a
motor vehicle?
Examples, including but not limited to: Diagnosis or treatment for heart trouble, stroke, hemorrhage or clots, high blood pressure, emphysema
(within the past two years) • progressive eye disorder or injury (i.e., glaucoma, macular degeneration, etc.) • loss of normal use of hand, arm, foot
or leg • blackouts, seizures, loss of consciousness or body control (within the past two years) • difficulty turning head from side to side • loss of
muscular control • stiff joints or neck • inadequate hand/eye coordination • medical condition that affects your judgment • dizziness or balance
problems • missing limbs
Please explain and identify your medical condition: ____________________________________________________________________________________________________________
20. ___ ___ Do you have a mental condition that may affect your ability to safely operate a motor vehicle? If yes, how? Please explain:
________________________________________________________________________________________________________________________________________________________________________
21. ___ ___ Have you ever had an epileptic seizure, convulsion, loss of consciousness, or other seizure?
22. ___ ___ Do you have any alcohol or drug dependencies that may affect your ability to safely operate a motor vehicle or have you had any episodes of
alcohol or drug abuse within the past two years?
23. ___ ___ Within the past two years have you been treated for any other serious medical conditions? Please explain:
________________________________________________________________________________________________________________________________________________________________________
24. ___ ___ Have you EVER been referred to the Texas Medical Advisory Board for Driver Licensing?
YES NO
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