Form Dl-14a - Application For Texas Driver License Or Identification Card Page 2

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DRIVER LICENSE APPLICANTS

The answers to questions 1 through 7 below are for the confidential use of the Department

YES

MEDICAL HISTORY QUESTIONS

Do you currently have or have you ever been diagnosed with or treated for any medical condition that may affect your ability to safely

operate a motor vehicle?

EXAMPLES, including but not limited to: Diagnosis or treatment for heart trouble, stroke, hemorrhage or clots, high blood pressure, emphysema (within

past two years) • progressive eye disorder or injury (i.e., glaucoma, macular degeneration, etc.) • loss of normal use of hand, arm, foot or leg • blackouts,

seizures, loss of consciousness or body control (within the past two years) • difficulty turning head from side to side • loss of muscular control • stiff joints or

neck • inadequate hand/eye coordination • medical condition that affects your judgment • dizziness or balance problems • missing limbs

Please explain and identify medical condition:

Within the past two years, have you been diagnosed with, been hospitalized for or are you now receiving treatment for a psychiatric disorder?

Have you ever had an epileptic seizure, convulsion, loss of consciousness, or other seizure?

Do you have diabetes requiring treatment by insulin?

Do you have any alcohol or drug dependencies that may affect your ability to safely operate a motor vehicle or have you had any episodes

of alcohol or drug abuse within the past two years?

Within the past two years have you been treated for any other serious medical conditions? Please explain:

Have you EVER been referred to the Texas Medical Advisory Board for Driver Licensing?

NOTICE: The information on this application is required by the Texas Driver License Act, Texas Transportation Code Chapter 521. Failure to provide the

information is cause for refusal to issue a driver license or identification card, and in some cases, cancellation or withdrawal of the driving privilege. False

information could also lead to criminal charges with penalties of a fine up to $4,000.00 and/or jail.

O NOT SIGN UNTIL INSTRUCTED TO DO SO BY

OTARY

UBLIC OR

RIVER

ICENSE EMPLOYEE

CERTIFICATION

I do solemnly swear, affirm, or certify that I am the person named herein and that the statements on this application are true and correct.

I further certify my residence address is a (check one): ( ) single family dwelling, ( ) apartment, ( ) motel, ( ) temporary shelter.

I agree to immediately report to the Texas Department of Public Safety any changes in my medical condition which may affect my ability to safely

operate a motor vehicle. I further understand that I am required by law to report any change of name or address to the Department of Public

Safety within thirty days.

Date:

Pursuant to Texas law, the Texas Department of Public Safety will provide every minor applicant (under age 18), and cosigner, for a driver

license in Texas, educational information concerning state laws relating to driving while intoxicated, driving by a minor with alcohol in the

minor’s system, and the implied consent law. The minor applicant and the cosigner must acknowledge receipt of that information prior to

issuance of any driver license or permit.

I hereby acknowledge receipt of the information concerning DWI, the Zero Tolerance Law and the Implied Consent Law.

Minor Applicant

Parent/Legal Guardian

Date of Receipt

PARENTAL AUTHORIZATION

Required for all driver license applicants under the age of 18

I do solemnly swear, affirm, or certify that I am the person named herein, that the statements on this application are true and correct,

that the above named applicant is my ( ) child ( ) stepchild ( ) ward, and that I have legal custody of the applicant. I authorize the Department

of Public Safety to issue a Class ( ) A, ( ) B, ( ) C, or ( ) M license to said minor.

Usual Written Signature of Parent or Guardian

Driver License Number

Date

WAIVER OF PARENTAL AUTHORIZATION

Parental Authorization waived. Authority

DL Employee

VERIFICATION

Sworn to and subscribed before me this

day of

Notary Public in and for the State of Texas/Authorized Officer

SOCIAL SECURITY NUMBER COLLECTION DISCLOSURE

Disclosure of your social security account number is mandatory for driver license applicants, but voluntary for identification card applicants. This informa-

tion is solicited pursuant to 42 U.S.C. 405(c)(2)(C)(i), 42 U.S.C. 666(a)(13)(A); 49 C.F.R. 383.153, Texas Family Code Section 231.302(c)(1) and Texas

Transportation Code Sections 522.021 and 521.142. The Department will use social security account number information for identification purposes and

will only release the number to the Child Support Enforcement Division of the Attorney General’s Office, the U.S. Selective Service Administration and the

Texas Secretary of State for statutorily authorized purposes pursuant to Texas Transportation Code Section 521.044.