Rev. 07/01/2020 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 or instruction permit
as your REAL ID-compliant card (with a star in a gold circle)?
YES NO
_ _ _ - _ _ - _ _ _ _
H __ __ __ __ __ __ __ __
DATE OF BIRTH (mm-dd-yyyy)
_ _ / _ _ / _ _ _ _
Do you wish to be an organ /
tissue donor?
FULL LEGAL NAME (Last, First, Middle, Suffix)
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 FEMALE
_____ ______ HAIR EYES DESIGNATION NOT SPECIFIED
Do you wish to have a Veteran
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.
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 disclosed will be used only for the purpose of
determining your eligibility to drive. The answers provided will be kept
confidential.
A) Within the past two years have you had a seizure or convulsion, stroke or
TIA (mini-stroke), suffered from any episodes of confusion, or had a
blackout spell? ………………………………………………………………… YES NO
B) Have you had a loss of consciousness or confusion due to high or low
blood sugar? ………………………………………..…………………………. YES NO
C) Do you have any trouble moving your body that keeps you from driving
safely? .…………….……………………………………….…………………….. YES NO
D) Do you use drugs or alcohol that affect your driving? ………. YES NO
E) Do you have Alzheimer’s, dementia or memory loss? ……… 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 or supporting documentation, 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).
DRIVER’S LICENSE/ INSTRUCTION PERMIT NUMBER
TYPE RESTRICTION EYE TEST
LE RE
