Fillable DL Application Form 2018 02 01 Rev Public Use (Hawaii)

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DL Application Form 2018 02 01 Rev Public Use (Hawaii)

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DL Rev. 02/01/2018 Page 1 of 2
STATE OF HAWAII DRIVER’S LICENSE APPLICATION
CHECK TRANSACTION REQUESTED
DRIVER’S LICENSE RENEWAL
INSTRUCTION PERMIT (New, Duplicate, Renewal)
DUPLICATE (Temporary, Lost, Name/Address Change)
OUT OF STATE TRANSFER
In accordance with 6 CFR Part 37.29 (a) and §286-306 (c), HRS, an individual may hold only one REAL ID-compliant card. An individual cannot hold a REAL ID-compliant State
ID card and REAL ID-compliant driver’s license. A REAL ID-compliant card is an accepted form of ID for domestic air travel and accessing Federal facilities.
Provided all REAL ID required documentation has been provided, do you wish to designate your driver’s license as your
REAL ID-compliant card (with a star in a gold circle)?
YES NO
SOCIAL SECURITY NUMBER
_ _ _ - _ _ - _ _ _ _
DRIVER’S LICENSE NUMBER
H __ __ __ __ __ __ __ __
DATE OF BIRTH (mm-dd-yyyy)
_ _ / _ _ / _ _ _ _
Do you wish to be an organ /
YES
tissue donor?
FULL LEGAL NAME (Last, First, Middle, Suffix)
Do you have an advance
YES
health-care directive? NO
MAILING ADDRESS (Street and Apt. or House No., or P.O. Box, City, State and Zip Code)
HAWAII PRINCIPAL RESIDENCE ADDRESS (Indicate SAME if address is the same as your Mailing Address above)
FT. IN. LBS. MALE
HEIGHT WEIGHT COLOR COLOR GENDER
_____ ______ HAIR EYES FEMALE
Do you wish to have a Veteran
YES
designation?
NOTE: Applicable to any person who served in
any of the uniformed services of the United
States and was discharged under conditions
other than dishonorable. Documentary
evidence required.
PHONE NO. (Optional)
BUSINESS ADDRESS (Street or P.O. Box, City, State and Zip Code)
1. Have you previously held a driver’s license in Hawaii,
another State or Country? ……………………………………………………. YES NO
If YES, ______________________________________
(State or Country) (Lic. No. & Exp. Date)
2. WITHIN THE LAST THREE (3) YEARS, have you:
A) Ever been convicted in the State of Hawaii for driving
without a license? …………………………………………………………… YES NO
If YES, ______________________________________
(County) (Date)
B) Had an application for any driver’s license refused?........... YES NO
If YES, ______________________________________
(Date) (Reason)
C) Had any such license suspended or revoked? ……………….… YES NO
If YES, ______________________________________
(Date) (Reason)
Has such license been reinstated? .…………………………………. YES NO
D) Ever been required to deposit proof of Financial
Responsibility under the Motor Vehicle Financial
Responsibility laws of the State of Hawaii? …………………….. YES NO
3. ARE YOU WEARING CONTACT LENSES? ……………………………….… YES NO
4. The medical information in the following three questions will be
used only for the purposes of determining your eligibility to drive.
The answers to the questions will be kept confidential.
A) Check off the medical condition(s) experienced within the last two years?
Neurologic/Orthopedic/Arthritic Conditions Diabetes
Seizure/Stroke/Blackout Spells Chronic Alcoholism
Drug Addiction Heart/Lung Condition
Other: (Explain) ____________________________________________
____________________________________________
B) Within the last two years, have you had a loss of
consciousness or physical control, which affected your
functional ability to safely operate a motor vehicle? ………… YES NO
C) Has your ability to drive been impaired (due to injury or
illness) within the last two years? …………………………………….. YES NO
I hereby certify, under penalty of perjury, that all of the information provided is true and correct and that I am the person named and described in this application. I
understand that providing false information may be a violation of Federal and State law.
APPLICANT’S SIGNATURE ____________________________________________________________ DATE __________________________
NOTE: ALL DRIVER’S LICENSE RECORDS WILL BE VERIFIED THROUGH THE NATIONAL DRIVER REGISTER FOR STOPPER INFORMATION. ALL DENIED APPLICATIONS WILL
REQUIRE WRITTEN CLEARANCE FROM THE JURISDICTION(S) THAT PLACED THE STOPPER(S).
Advance health-care directive means an individual instruction, in writing, a living will, or a durable power of attorney for health-care decisions.
Section 286-102.5, Hawaii Revised Statutes requires all male applicants between the ages of 18 through 25 to be automatically registered with the United States Selective
Service System. By submitting this application for the issuance of a permit, license, duplicate or renewal, the qualified applicant is consenting to registration with the United
States Selective Service System, if so required by Federal law.
I acknowledge that my SOCIAL SECURITY number I am providing is as required by Sections 19-122-1, 19-122-3, 19-122-23, 19-122-302 and 19-122-307, Hawaii Administrative
Rules, Section 286-111, Hawaii Revised Statutes, and in accordance with Section 7 of the Privacy Act and 42 United States Code, Section 405(c)(2)(c). I further acknowledge
my SOCIAL SECURITY number, or if I am unable to obtain a social security number as evidenced by official notification by the Social Security Administration to the county
driver licensing office, or unwilling to provide a social security number, an assigned substitute number shall be issued by this agency for the sole purpose of providing me
with a driver’s license. Your social security number or assigned substitute number will not be printed on your card.
IMPLIED CONSENT LAW: I agree to submit to a chemical test or tests of my blood, breath or urine for the purpose of determining the alcohol or drug content of my blood
when testing is requested by a police officer acting in accordance with Section 291E-11, Hawaii Revised Statutes (HRS). The license of anyone who refuses to be tested shall
be subject to administrative revocation pursuant to Section 291E-41, HRS.
MOTOR VOTER: The Driver’s License Application will be used to update the voter registration record of currently registered voters in the State of Hawaii, unless the
applicant affirmatively declines on page 2 of this application (National Voter Registration Act of 1993).
For Office Use Only
DRIVER’S LICENSE/ INSTRUCTION PERMIT NUMBER
TYPE RESTRICTION EYE TEST
LE RE
Clear Form
DL Rev. 02/01/2018 Page 2 of 2
Voter Registration and Permanent Absentee Application
To register to vote or to receive an absentee ballot permanently by mail review the information and complete the application below. If you
are currently registered to vote in the State of Hawaii, the information provided will be used to update your voter registration record.
I do not want the information on this form to be used to update my voter registration record.
DRIVER’S LICENSE NUMBER
H __ __ __ __ __ __ __ __
DATE OF BIRTH (mm-dd-yyyy)
_ _ / _ _ / _ _ _ _
FULL LEGAL NAME (Last, First, Middle)
MAILING ADDRESS (Street and Apt. or House No., or P.O. Box, City, State and Zip Code)
HAWAII PRINCIPAL RESIDENCE ADDRESS (Indicate SAME if address is the same as your Mailing Address above)
PHONE NUMBER
EMAIL ADDRESS
QUALIFICATIONS
If you answer “No” to any of the questions below, DO NOT complete this form.
Are you a citizen of the United States of America? Yes No
Are you at least 16 years of age? (Must be 18 to vote) Yes No
Are you a resident of the State of Hawaii? Yes No
The residence stated in this affidavit is not simply because of my presence in the State, but was acquired with the intent to make Hawaii my legal residence with all the
accompanying obligations therein.
ARE YOU REGISTERED TO VOTE IN ANOTHER STATE? Provide your last registered address, county, state, and zip code.
Yes. I hereby authorize cancellation of my previous registration.
WOULD YOU LIKE TO PERMANENTLY RECEIVE ABSENTEE BALLOTS BY MAIL?
Yes. I request to permanently receive absentee ballots at the mailing address associated with my voter registration.
I understand that my permanent absentee voter status will be terminated if: 1) I request termination in writing; 2) I die, lose voting rights, register in another jurisdiction,
or am otherwise disqualified from voting; 3) my absentee ballot, voter notification postcard, or any other election mail is returned to the clerk as undeliverable for any
reason; or 4) I do not return my ballot by 6:00 PM on election day in both the primary and general election of an election year. If so, I understand that I must reapply for
permanent absentee status.
WARNING: Any person who knowingly furnishes false information may be guilty of a Class C felony.
I hereby swear (or affirm) that all information furnished on this application is true and correct.
Signature: Date:
Office Use Only
ID Number
DL99
Location Code
98
Document Number
Notice: The identity of the voter registration agency through which any particular voter was registered shall not be publicly disclosed. A person’s declination to register to
vote is also confidential and is used for voter registration purposes only (National Voter Registration Act of 1993).
For election information, call the State of Hawaii Voter Hotline at 1-800-442-VOTE (8683)
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DL Application Form 2018 02 01 Rev Public Use (Hawaii)

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Completed 20 February 2021

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