Fillable IDENTIFICATION CARD APPLICATION (City and County of Honolulu)

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IDENTIFICATION CARD APPLICATION (City and County of Honolulu)

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BROWSE CITY AND COUNTY OF HONOLULU (HI) FORMS

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Page 1 of 2
Rev
. 07/01/2020
STATE OF HAWAII
IDENTIFICATION CARD APPLICATION
CHECK TRANSACTION REQUESTED: INITIAL
RENEWAL
DUPLICATE
FOR OFFICE USE ONLY: SID NUMBER
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.
Do you currently hold a valid REAL ID-compliant driver’s license, instruction permit or State identification card issued by
Hawaii or another U. S. jurisdiction? YES NO
SOCIAL SECURITY NUMBER
____ ____ ____ ____ ____ ____ ____ ____ ____
STATE ID NUMBER
S ____ ____ ____ ____ ____ ____ ____ ____
DATE OF BIRTH (mm/dd/yyyy)
___ ___ ___ ___ ___ ___ ___ ___
FULL
LEGAL
NAME
LAST
FIRST
MIDDLE, SUFFIX
MAILING
ADDRESS
STREET OR P.O. BOX
CITY
STATE/ COUNTRY
ZIP CODE
HAWAII
PRINCIPAL
RESIDENCE
ADDRESS
STREET ADDRESS
CITY
STATE/ COUNTRY
ZIP CODE
HEIGHT
FEET
INCHES
WEIGHT
LBS.
COLOR HAIR
COLOR EYES
GENDER MALE
DESIGNATION FEMALE
NOT SPECIFIED
PLACE OF
BIRTH
CITY / STATE / COUNTRY
OCCUPATION
DO YOU WISH TO BE AN
ORGAN / TISSUE DONOR?
YES
DO YOU HAVE AN ADVANCE
HEALTH-CARE DIRECTIVE?
YES NO
DO YOU WISH TO HAVE A VETERAN DESIGNATION?
YES
NOTE: Applicable to any person who served in any uniformed services of the
United States and was discharged under conditions other than dishonorable.
Documentary evidence required.
CITIZENSHIP
EMERGENCY
CONTACT
NAME (LAST, FIRST)
RELATIONSHIP
EMERGENCY
CONTACT
ADDRESS
STREET OR P.O. BOX
CITY
STATE/ COUNTRY
ZIP CODE
EMERGENCY
CONTACT
TELEPHONE
AREA CODE
NUMBER
OR
IDD PREFIX COUNTRY CODE NUMBER
I acknowledge that my social security number I am providing is as required by Sections 19-149-3 and 19-149-9, Hawaii Administrative Rules, Section 286-
303(c)(8), 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
that 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 examiner of drivers, an assigned substitute number shall be issued by this agency for the sole purpose of providing me with a state identification
card. Your social security number or assigned substitute number will not be printed on your card.
Federal law requires all male applicants between the ages of 18 through 25 to register with the United States Selective Service System. By submitting this
application or supporting documentation, for the issuance of a state identification card, duplicate or renewal, the qualified applicant is consenting to the automatic
registration with the United States Selective Service System, if so required by Federal law.
Pursuant to Act 233, SLH 2019, a non-compliant state identification card shall be issued to an applicant who has physical or intellectual disabilities for whom
application in person would cause a serious burden. A licensed primary care provider must certify that a severe disability causes the applicant to be homebound.
The Identification Card 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).
I hereby certify, under penalty of perjury, that all 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 _______________________________
Clear Form
Page 2 of 2
Rev. 07/01/2020
Voter Registration Application
To register to vote, 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. All registered voters
will receive a ballot in the mail.
I do not want the information on this form to be used to update my voter registration record.
STATE ID NUMBER
S ____ ____ ____ ____ ____ ____ ____ ____
DATE OF BIRTH (mm/dd/yyyy)
___ ___
___ ___ ___ ___ ___ ___
FULL
LEGAL
NAME
LAST
FIRST
MIDDLE, SUFFIX
MAILING
ADDRESS
STREET OR P.O. BOX
APT. NO.
CITY
STATE/ COUNTRY
ZIP CODE
HAWAII
PRINCIPAL
RESIDENCE
ADDRESS
STREET ADDRESS
APT. NO.
CITY
STATE/ COUNTRY
ZIP CODE
CONTACT
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.
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 voter registration application is true and correct.
Signature: Date:
Office Use
Only
ID Number
SSID
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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IDENTIFICATION CARD APPLICATION (City and County of Honolulu)

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Completed 25 November 2020

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