Fillable STATE OF MISSISSIPPI DEPARTMENT OF PUBLIC SAFETY Application (Mississippi)

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STATE OF MISSISSIPPI DEPARTMENT OF PUBLIC SAFETY Application (Mississippi)

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For questions or information, contact the Driver Records Division
P.O. Box 958, Jackson, MS 39205‐0958
Phone: (601) 987‐1224 | www.driverservicebureau.dps.ms.us
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STATE OF MISSISSIPPI
DEPARTMENT OF PUBLIC SAFETY
Application for Mississippi Driver License/ID
(To be completed by applicant in black ink or typed)
PLEASE MAKE YOUR SELECTION BELOW
LICENSE PERMIT ID OTHER
Regular Driver License (Class R)
Light Commercial (Class D)
Commercial Driver License:
(Choose CDL Type)
A B C
Learner's Permit
Driver's Ed Learner's Permit
Motorcycle Permit
Commercial Learner's Permit:
(Choose CLP Type)
A B C
State ID card
Disability ID card
Blind ID card
Name or Address Change
Update Address Notification ‐ No card
RESTRICTIONS ENDORSEMENTS
Full/Partial Air Brakes
No Air Brakes
P‐Passenger
S‐School Bus
N‐Tank
T‐Doubles/Triples
H‐Hazmat
L‐Motorcycle
PERSONAL INFORMATION
MS License/ID/Permit Number: Social Security Number:
Legal Name:
Last: First: Middle/Maiden: Suffix:
Date of Birth:(Mo/Day/Year) Sex: Hair: Eyes: Height (ft/in): Weight (lbs): Race:
Ethnicity:
Age:
Place of Birth:(City, State, Country)
Residential Address:
Check here if t
his address is not to be used for voter registration purposes.
Street 1: City:
Street 2: State: ZIP:
Mailing Address (if different than Residential Address):
Street 1: City:
Street 2: State: ZIP:
Contact Information:
Home Phone:
Cell Phone
(required if Text Messaging is requested):
Work Phone:
Email
Address:
Contact Preference:
Please indicate how you would like to be contacted. This will become the default method for how we communicate with you:
Text Msg
Email
US Mail
YES NO ANSWER THE QUESTIONS BELOW:
1.
Have you ever held a driver license or ID card in Mississippi or any other state? If YES, What state?
When?
ID or DL Number:
2.
Has your license or driving privilege ever been suspended, revoked or cancelled? If YES, What state?
When?
DL Number: For what reason?
3.
Have you ever been denied a license? If YES, Why?
4.
Are you a United State Citizen? (If NO, you must present your valid Immigration documents)
5.
If you are a veteran of the US Armed Forces, do you wish to have a Veteran Indicator printed on your driver license
(Special Documentation Required)?
6.
Are you hearing impaired?
If YES, would you like an indicator for your condition on your license/ID?
7.
Do you have diabetes?
If YES, would you like an indicator for your condition on your license/ID?
8.
Do you wish to have an Autism Spectrum Disorder indicator on your license/ID?
UNDER 17 YEARS OLD MUST SHOW A CERTIFIED BIRTH CERTIFICATE, SOCIAL SECURITY CARD, SCHOOL FORM, TWO (2) PROOFS OF RESIDENCE, AND THIS
APPLICATION
MUST BE SIGNED BY BOTH PARENTS AND NOTARIZED (SEE BOTTOM OF THIS FORM). OUT
‐
OF
‐
STATE LICENSED DRIVERS MUST PRESENT OUT
‐
OF
‐
STATE LICENSE,
SOCIAL SECURITY CARD (ISSUED BY SOCIAL SECURITY ADMINISTRATION), BIRTH CERTIFICATE, AND TWO (2) PROOFS OF RESIDENCE.
ALL NAME CHANGES ON LICENSE
MUST BE SUPPORTED BY APPROPRIATE DOCUMENTS SUCH AS MARRIAGE LICENSE, ADOPTION PAPERS, DIVORCE DECREE,
OR COURT ORDER; ONLY ORIGINALS ARE
ACCEPTABLE.
CDL APPLICANTS MUST PRESENT A VALID MEDICAL EXAMINER'S CERTIFICATE BEFORE COMMERICAL LEARNER'S PERMIT (CLP) CAN BE ISSUED.
APPLICANTS MUST HOLD COMMERCIAL LEARNERS PERMIT (CLP) FOR FOURTEEN (14) DAYS BEFORE CDL SKILLS TESTING CAN BE CONDUCTED.
/
/
For questions or information, contact the Driver Records Division
P.O. Box 958, Jackson, MS 39205‐0958
Phone: (601) 987‐1224 | www.driverservicebureau.dps.ms.us
CRED01b
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3.0
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SELECTIVE SERVICE
By submitting this application, I am consenting to registration with the Selective Service System, if so required by law when I reach eighteen years of age. Any male who
is at least eighteen (18) years of age but less than twenty‐six (26) years of age and who applies for a permit or license or a renewal of a permit or license shall be
registered in compliance with the requirements of Section 3 of the Military Selective Service Act 50 USCS Appx 451 et seq. as amended.
The applicant’s submission of the application shall serve as an indication that the applicant either has already registered with the Selective Service System or that he is
authorizing the department to forward to the Selective Service System the necessary information for registration. Submission of the application will serve as his consent
to registration with the Selective Service System, if so required. Any male applicant under the age of eighteen (18) will be registered upon turning age eighteen (18) as
required by federal law.
ORGAN/TISSUE DONOR
Do you wish to be or continue to be registered as an organ & tissue donor? You must be 18 yrs. of age or older. Yes No
VOTER REGISTRATION
Would you like to apply to register to vote or update your existing voter registration?
If you choose to register to vote or have your existing voter registration updated with your current information, you must meet all the conditions in the Voter Declaration below.
The office at which you register to vote is confidential and will be used only for voter registration purposes.
VOTER DECLARATION
I swear/affirm that:
I am a U.S. citizen,
I am at least eighteen (18) years old (or I will be before the next general election),
I will have lived in this state and county for at least 30 days before voting, and if a resident of a municipality, I will have lived in the municipality for at
least 30 days before voting.
I have never been convicted of murder, rape, bribery, theft, arson, obtaining money or goods under false pretense, perjury, forgery, embezzlement, or
bigamy, or I have had my rights restored as required by law,
I have not been declared mentally incompetent by a court.
Furthermore, I certify that the information given by me is true and correct and that I have truly answered all questions on the application for registration,
and that I will faithfully support the Constitution of the United States and of the State of Mississippi, and will bear true faith and allegiance to the same.
Sign here ONLY if you choose to register to vote or have your voter registration updated.
Signature: _________________________________________________________________
The penalty for conviction of false registration under MS Code §97‐13‐25 is imprisonment in the State Penitentiary for not more than five (5) years, or to be fined
not more than Five Thousand Dollars ($5,000), or both.
SEX OFFENDER REGISTRATION
Notice: Persons who are convicted of any registerable sex offense must report to the Sheriff of the county of their residence and also the DPS for appropriate
sex offender registration. Authority: MCA 45-33-27. I acknowledge that I have read and understand the requirement to register as a Sex Offender as set forth
above.
CANCELLATION OF DL/CDL/ID CARD FROM ANOTHER JURISDICTION
I understand that, upon issuance of a Driver License or Identification Card in the State of Mississippi, any driver license or identification card previously
issued by a
nother state will be cancelled. I also understand that if a driver license or identification card is later issued in another state, my Mississippi
Driver License or Identification Card will be cancelled.
AFFIRMATION/SIGNATURE
I DO SOLEMNLY SWEAR/AFFIRM THAT, UNDER THE PENALTIES OF PERJURY, I AM THE PERSON NAMED AND DESCRIBED HEREIN AND THAT THE
STATEMENTS ON THIS APPLICATION ARE TRUE AND CORRECT. ALSO, BY SUBMITTING THIS APPLICATION, I AFFIRM THAT THE LICENSE CLASS I HAVE
REQUESTED IS REPRESENTATIVE OF THE VEHICLE CLASS I INTEND TO DRIVE. FURTHER, I UNDERSTAND THAT, IF I CURRENTLY HOLD A COMMERCIAL
DRIVER LICENSE BUT HAVE NOT SELECTED A SIMILAR CDL LICENSE, I WILL BE DOWNGRADED TO A REGULAR LICENSE.
USUAL Signature of Applicant Date
UNDER 17 YEARS OF AGE
THE UNDERSIGNED AGREE TO ACCEPT THE RESPONSIBILITY FOR ANY NEGLIGENCE OR WILLFUL MISCONDUCT OF THE PERSON NAMED IN THIS APPLICATION
WHILE HE/
SHE IS OPERATING A MOTOR VEHICLE AND TO BE LIABLE FOR DAMAGES RESULTING FROM SUCH MISCONDUCT OR NEGLIGENCE.
Under
17
SIGNATURE OF BOTH PARENTS OR PROVIDE REASON FOR NOT SIGNING
Divorce Deceased
Other
OPERATOR'S LICENSE NO. ADDRESS IF DIFFERENT THAN APPLICANT
FATHER/Parental Guardian
MOTHER/Parental Guardian
Subscribed and sworn to before me:
__________________________________ _______________________________________________________________________________ __________________________________________________________
Date
Official Signature and Seal of Notary Title
/
/
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STATE OF MISSISSIPPI DEPARTMENT OF PUBLIC SAFETY Application (Mississippi)

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Completed 13 May 2022

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