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(Cardholder-Sign Name in Full)
CERTIFICATION
SIGN HERE
1. Have you had, or are you being treated for
, any of the following, or has a previous disability worsened?
o Yes o No If “Yes”, check all that apply.
o 1. Convulsive disorder, epilepsy, fainting or dizzy spells, or any condition which causes unconsciousness
o 2. Heart ailment
o 3. Hearing impairment
o 4. Lost use of leg, arm, foot, hand, or eye
o 5. Other (explain)____________________________________________________________________________________________________________
2. Have you had a driver license, learner permit, or privilege to operate a motor vehicle suspended, revoked or cancelled, or an application for a license denied
in this state or elsewhere, in this or any other name?
o Yes o No
If “Yes”, has your license, permit or privilege been restored, or your application approved? o Ye s o No
MV-44 (9/12)
o Junior License o Non-driver ID Card (under 16)
I am the parent or guardian of the applicant, and I consent to the issuance of a learner permit, license or (if under 16) a non-driver ID card to him/her. I
understand that I am responsible for certifying that the applicant has completed at least 50 hours of supervised “practice” driving, including 15 hours of driving
after sunset, prior to the applicant taking a road test, and that this certification (MV-262) must be presented at the time of the road test. Note to parent/guardian:
If the driver license applicant is 17 years old and has a Driver Education Student Certificate of Completion (MV-285), consent is not required.
Parent or Guardian
Sign Here
PLEASE PRINT
NAME
My signature authorizes_______________________________________________
to use my credit card for payment of fees in connection with this application, and I
understand that I must be present for this transaction.
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(Relationship to Applicant) (Date)
I certify that the information I have given on this application is true. If I am applying for a replacement license or non-driver
identification card, I certify that the license or non-driver identification card has been lost, stolen or mutilated and that, if the lost license or non-driver
identification card is found, I will turn it in to the Department of Motor Vehicles. If I am exchanging my out-of-state license for a NYS license, I certify
that I was a permanent resident of the state or province in which my license was issued at the time the license was issued, that such license has been
valid for at least 6 months, and that I have not failed a road test in NYS in the last 12 months. If I am a male at least 18 but less than 26 years old, I
consent to be registered with the Selective Service System, if so required by federal law, and authorize the forwarding of any personal information
required for such registration. My signature below also authorizes use of my credit card, if applicable.
DRIVER LICENSE and LEARNER PERMIT APPLICANTS ONLY
PARENT/GUARDIAN CONSENT
I would like to enroll in the TEENS program to be notified if the under 18 year-old applicant
receives a conviction, suspension, revocation or an accident on their license file. For more
information about this program, see form MV
-1046, How to Enroll in TEENS or MV-1056,
TEENS FAQs. This is a FREE service.
Teen Electronic Event Notification Service (TEENS)
COMMERCIAL DRIVER LICENSE APPLICANTS ONLY
CREDIT CARD AUTHORIZATION IF CARDHOLDER IS NOT THE APPLICANT:
TEST RESULTS
Eye
o Pass o Corrective Lens
1
2
Written
o Pass o Fail
Applicant’s Signature
Examiner’s Initials
2. Do you certify that you meet the federal requirements in 49 CFR Part 391 and you have a valid Medical Examiner’s Certificate? o Yes o No
If YES, you must submit a copy of your Medical Certificate and if you have one, a Skills Performance Evaluation Certificate or diabetes or vision waiver.
If NO, you must answer questions 3a and 3b below:
3a. Will you drive commercially only for municipal operations, school operations, or both? o Yes o No
If YES, you will be issued a CDL with an A3 restriction that will allow you to drive only for municipal operations, school operations, or both.
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If you checked box 1, you and your doctor must complete form MV-80U.1, “Physician’s Statement for Medical Review Unit”; if you checked box 2, your doctor
must complete form MV-80, “Physician’s Statement”. These forms can be obtained at any Motor Vehicles office or at www.dmv.ny.gov. If you checked boxes
3, 4 or 5, you must contact a Motor Vehicles office for instructions.
NYS Client ID of Consenting Parent or Guardian Above- Required
IMPORTANT: Making a false statement in any license or non-driver ID card application, or in any proof or statement in connection with it, or
deceiving or substituting, or causing another person to deceive or substitute in connection with such application, may subject you to criminal
prosecution for a misdemeanor or felony under the Vehicle and Traffic Law and/or the Penal Law.
3b. Will you drive commercially only within New York State? o Yes o No
If YES and your first CDL was issued before 9/9/99, you will be issued a CDL with a K restriction that will allow you to drive commercially only within New York State.
If all answers to questions 2, 3a and 3b are NO, you are not eligible for a CDL.
NOTE: If additional information is needed please obtain form MV-44.5.
1. In the past 10 years, was a driver license issued to you from another state in the U.S. or the District of Columbia ?
o Yes o No
If YES, write the name of each one (if you turn in a license from another state, do not include that state):
