CERTIFICATION
I certify and affirm that I am a resident of Virginia, that all information presented in this application is true and correct, that any documents I have presented to
DMV are genuine, and that my appearance, for purpose of my DMV photograph, is a true and accurate representation of how I generally appear in public. I make
this certification and affirmation under penalty of perjury and understand that making a false statement on this application is a criminal violation. By signing this
form, I authorize DMV to verify the information provided on this application, as required to determine eligibility.
DATE (mm/dd/yyyy)
APPLICANT SIGNATURE APPLICANT NAME (print)
GOVERNMENT EMPLOYEES - (Fee waiver certification)
I certify that I am employed by the:
to operate a motorcycle solely in the course of this employment and, because of such employment, I am entitled to the waiver of the motorcycle class
endorsement fee, provided I have paid for and hold a valid Virginia driver's license or have made application for such.
Town ofCounty ofCity of Commonwealth of Virginia or
Va. Code §§46.2-323 and 46.2-342 require that you provide DMV with the information on this form (including your social security number). Your personally
identifiable information is being collected for record keeping purposes and will be disseminated only in accordance with Va. Code §§46.2-208, 46.2-209, and the
Driver’s Privacy Protection Act, 18 USC §2721. Persons convicted of certain sexual offenses (as listed in Va. Code §9.1-902) must register or re-register with the
Virginia Department of State Police as provided in Va. Code §§9.1-901, 9.1-903, and 9.1-904. If you provide a non-Virginia residence/home address or non-
Virginia mailing address, your application for a driver’s license or permit may be denied. Upon issuance of a driver’s license, commercial driver's license or
identification card in the Commonwealth of Virginia, any driver’s license, commercial driver's license or identification card previously issued by another state must
be surrendered and will be cancelled by the issuing state.
NOTICE
SIGNATURE (check one and sign)
EMANCIPATED MINORPARENT / GUARDIAN JUDGE, JUVENILE DOMESTIC RELATIONS COURT
All males under the age of 26 are required to check one of the following. Failure to provide a response will result in denial of your application.
By signing this application, I consent to be registered with Selective Service, if required by federal law. If under age 18, an appropriate adult must complete and
sign below: I authorize DMV to send information to Selective Service which will be used to register applicant when he is 18 years old.
I am already registered with Selective Service.
I am a non-immigrant alien in the U.S. and not required to register.
I authorize DMV to forward to the Selective Service System personal information necessary to register me with Selective Service.
SELECTIVE SERVICE
APPLICANT UNDER AGE 18 Have you ever been found not innocent of any offense in a Juvenile and Domestic Relations Court in this or any other state?
YES NO
If you answered YES, the court making the adjudication of “not innocent” or a court within the jurisdiction where the juvenile’s parent/guardian resides must provide court consent below.
COURT CONSENT In my opinion the applicant's request for a learner's permit/driver's license
should be granted. should not be granted.
REMARKS:
PARENT/GUARDIAN NAME (print) PARENT/GUARDIAN SIGNATURE DATE (mm/dd/yyyy)
DATE (mm/dd/yyyy)JUDGE SIGNATURE JUDGE NAME (print)
Check applicable box, review certification statement, print your name and sign where indicated.
I authorize issuance of a learner's permit/driver's license. I certify that the applicant is a resident of Virginia. I certify that the applicant is
attending school regularly and is in good academic standing, but if not, I authorize issuance of a learner's permit/driver's license. I certify that this applicant
will operate a motor vehicle for at least 45 hours (15 of which will occur after sunset) while holding a learner's permit.
If the applicant attends public school, I authorize the principal or designee of the public school attended by the applicant to notify the juvenile and domestic
relations district court (within whose jurisdiction the applicant resides) when the applicant has had 10 or more unexcused absences from school on
consecutive school days.
If a Special Indicator Request is checked on this application, I request on behalf of the applicant that it be shown on the learner's permit/driver's license.
I certify that the statements made and the information submitted by me are true and correct.
I authorize issuance of an ID card. If the applicant is under age 18, I certify that the applicant is a resident of Virginia. If a Special Indicator Request is
checked on this application, I request on behalf of the applicant that it be shown on the identification card.
I certify that the statements made and the information submitted by me are true and correct.
PARENT OR LEGAL GUARDIAN LICENSE CONSENT
VETERAN INDICATOR
I would like to add/keep the veteran indicator on my driver's license or identification card.
I would NOT like to add/keep the veteran indicator on my driver's license or identification card.
You must complete a Virginia Veteran Military Service Certification (DL 11) form and provide an acceptable veteran service proof document to add the veteran
indicator, unless you have already done so.
Do you currently have or have you ever held a license, ID card or learner's permit from another state, U.S. territory or foreign country?
If yes, provide the following:
LICENSE/ID CARD NUMBER ISSUE DATE (mm/dd/yyyy) EXPIRATION DATE (mm/dd/yyyy) STATE/COUNTRY
Yes No
APPLICANT INFORMATION (continued)
DL 1P (01/15/2020)
