FIRST NAME, LAST NAME AND PRIMARY TELEPHONE NUMBER ARE REQUIRED
(Contact must be a person 18 years of age or older)
CONTACT FIRST NAME CONTACT LAST NAME PRIMARY TELEPHONE NUMBER
CONTACT STREET ADDRESS CITY STATE ZIP CODE
COUNTRY
ARE YOU RELATED TO
THE CONTACT?
YES NO
SECONDARY TELEPHONE NUMBER
CONTACT 1
EMERGENCY CONTACT INFORMATION (continued)
CONTACT 2
FIRST NAME, LAST NAME AND PRIMARY TELEPHONE NUMBER ARE REQUIRED
(Contact must be a person 18 years of age or older)
CONTACT FIRST NAME CONTACT LAST NAME PRIMARY TELEPHONE NUMBER
CONTACT STREET ADDRESS CITY STATE ZIP CODE
COUNTRY
ARE YOU RELATED TO
THE CONTACT?
YES NO
SECONDARY TELEPHONE NUMBER
Please ensure the emergency contact information provided is up to date and accurate. Virginia DMV is not responsible for any errors in the information
provided. In the event of an emergency, this contact information may be disclosed to emergency personnel. Per Virginia statute, DMV is immune from
liability if the designated person(s) listed cannot be contacted.
IMPORTANT INFORMATION IF PARTICIPATING IN EMERGENCY CONTACT PROGRAM
CERTIFICATION
Parent/Legal Guardian, check the box if you give consent for this minor to become an organ, eye and tissue donor and
for the Department of Motor Vehicles (DMV) to display this information on his/her identification card.
I certify and affirm that my child is 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 child's appearance, for purpose of this DMV photograph, is a true and accurate representation of how he/
she generally appears in public. I make this certification and affirmation under penalty of perjury and understand that knowingly 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.
PARENT/LEGAL GUARDIAN NAME (print)
PARENT/LEGAL GUARDIAN SIGNATURE DATE (mm/dd/yyyy)
DL 5 (07/01/2020) -- Page 2
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, 46.2-345, 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 an identification card may be denied. Upon
issuance of an identification card in the Commonwealth of Virginia, any driver’s license or identification card previously issued by another state must be
surrendered and will be cancelled by the issuing state.
NOTICE
EMANCIPATED MINORPARENT / GUARDIAN JUDGE, JUVENILE DOMESTIC RELATIONS COURT
SELECTIVE SERVICE
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.
SIGNATURE (check one and sign)
