Fillable Form 1.: DEPARTMENT OF MOTOR VEHICLES (State of Connecticut/Department of Administrative Services)

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Form 1.: DEPARTMENT OF MOTOR VEHICLES (State of Connecticut/Department of Administrative Services)

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U.S.A. forms for State of Connecticut/Department of Administrative Services

BROWSE STATE OF CONNECTICUT/DEPARTMENT OF ADMINISTRATIVE SERVICES (CT) FORMS

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( LP
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
BRANCH OPERATIONS DIVISION
INSTRUCTIONS:
1.
2.
Applicant must complete and sign this application. Type or print clearly.
Applicant must present the required evidence of identity.
OFFICE USE ONLY
APPLICATION FOR: (Check One)
LEARNER'S PERMIT
DRIVER'S LICENSE
COMMERCIAL DRIVER'S LICENSE (CDL)
MOTORCYCLE LEARNER'S PERMIT
COMMERCIAL LEARNER'S PERMIT (CLP)
NON-DRIVER IDENTIFICATION CARD
REASON FOR DUPLICATE/REPRINT (Check one)
LOST STOLEN DESTROYED
HEIGHT OF OPERATOR
ft. in.
OPERATOR'S NAME (Last, First, Middle) DATE OF BIRTH
RESIDENT ADDRESS (No. & Street) (City or Town) (State) (Zip Code)
FORMER NAME AND/OR ADDRESS IF RECENTLY CHANGED
The information provided to the Commissioner of Motor Vehicles herein is subscribed by me, the undersigned, under penalty of false statement, in
accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes. I understand that if I make a statement which
I do not believe to be true, with the intent to mislead the Commissioner, I will be subject to prosecution under the above-cited laws.
SIGNATURE OF OPERATOR DATE SIGNED
X
APPLICATION FOR DUPLICATE OF CURRENT PERMIT,
DRIVER'S LICENSE, ID CARD OR REPRINT OF TEMPORARY
1-B REV. 6-2017
REPRINT TEMPORARY LICENSE ID)
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Form 1.: DEPARTMENT OF MOTOR VEHICLES (State of ConnecticutDepartment of Administrative Services)

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Completed 2 September 2021

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