KANSAS DEPARTMENT OF REVENUE
CREDENTIAL REQUEST FOR KANSAS RESIDENTS TEMPORARILY OUT OF KANSAS
DEMI-1 Application 2
1. Ent
er your information in the below fields
Name: License #: DOB:
Email:
Phone #:
Date:
Kansas Address: Out of State/Country Mailing Address:
2. Select Your Application Type
☐ Replacement ☐ Extension ☐ Renewal
Military Member Only Options
☐ Concealed Carry ☐ Name Change ☐ Add Motorcycle
3. Answer the following questions entirely and accurately
1. Is your permanent residence located in Kansas? ☐ No ☐ Yes
2. A
re you a lawful resident of the United States? No Yes ☐ ☐
3. Do you understand that your answers to these questions, if answered falsely may be grounds for
prosecution? ☐ No Yes ☐
4. I
s your license now, or has it ever been suspended/revoked in Kansas or any other state?
No Yes Where? Why?
☐ ☐
5. Do you currently have any physical or mental disabilities that could make it difficult to operate a
motor vehicle safely? ☐ No Yes What are they?
☐
6. Have you suffered a seizure in the last 6 months? No Yes ☐ ☐
7. A
re you currently a habitual user of alcohol or drugs? No Yes ☐ ☐
8. D
o you have a pending suspension, restriction, or revocation in Kansas or any other state?
N
o Yes Where? ☐ ☐
9. Do you give your authorization to be listed as an organ, eye, and tissue donor? No Yes ☐ ☐
4.
Enter Fee Information
Fee Total: $
Payment Type: ☐ Money Order Check ☐ Credit Card ☐
If paying by card, complete the following: (A 2.5% processing fee will be added)
Card Type:
VISA MASTER CARD ☐ AMERICAN EXPRESS DISCOVER ☐ ☐ ☐
Card Number:
Card Expiration Date:
5. Signature:
By signing this form, I affirm that all the information provided on this application is true & correct
6. Email or mail your application, payment, and document copies
Email: KDOR_DEMI1@KS.GOV
Mail: Driver Services PO BOX 2188 Topeka, KS 66601
For questions, please email KDOR_DL@KS.GOV
