Form Vl-21 50m - Application For License/permit Page 3

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Questions/Certifications

 Yes  No

Do you need glasses or contact lenses when driving?

 Yes  No

I certify that I am a Vermont Resident

Do you have a history of a physical or mental condition including diabetes, epilepsy, seizures or blackouts (other than properly

 Yes  No

corrected eyesight) that could affect your ability to safely operate a motor vehicle? If ‘Yes’ you must submit a universal medical

report

(DMV Form VS-113)

to DMV.

I am a veteran of the US Military & I want “VETERAN” printed on my License.

Vermont Certificate of Veteran Status (DMV

 Yes  No

Form VG-168)

must also be included (unless previously submitted).

 Yes  No

Are you a U.S. Citizen, or

 Yes  No

If 5a is no, Do you have proof of legal presence?

 Yes  No

Do you wish to be registered as an organ & tissue donor?

 Yes  No

If your License contains a school bus endorsement, do you wish to keep it? (additional testing and documentation required)

 Yes  No

If your License contains a motorcycle endorsement, do you wish to keep it? ($3 additional per year)

If address change required for voter registration, complete voter registration section below.

Name, Address or Other Changes

Has your name changed?

Has your mailing address changed?

Has the physical address changed?

Other Change(s):



Yes

If applicable, list all former names exactly as they appeared on your previous licenses.

NOTE: If you do not check either box, you will be considered to have decided not to register to vote.

Voter Registration Questions

I am a U.S. Citizen AND I would like to apply to register to vote OR I am changing my address and I would like the Secretary of State to be notified?



Yes

No - I Decline to Register/Already Registered/I do not want to notify the Secretary of State

The last address at which I was registered to vote if any, was (Do Not Complete Unless Currently Registered to Vote at a Previous Address):

Street Address

City/Town

County

State

Every voter must take the voter’s oath below before voting for the first time in Vermont. You can attest for yourself

VOTER’S OATH (Vermont Constitution, Chapter II, Section 42)

that you have taken the oath or you can have any person over 18 attest that you have taken the oath below: You solemnly swear (or affirm) that whenever you give your vote or

suffrage, touching any matter that concerns the State of Vermont, you will do it so as in your conscience you shall judge will most conduce to the best good of the same, as

established by the Constitution without fear or favor of any person.



Yes

- I certify that I took the Voter’s Oath myself OR the voter's oath was administered to me by a person over eighteen.

I hereby affirm, under penalty of perjury, that the information on this form is true to the best of my knowledge. This declaration made under

penalties of 23 VSA § 202 & § 4110. Submission of a false voter registration application is subject to the penalties of perjury as provided in

17 V.S.A. § 2011 and in 42 U.S.C. § 1973 gg – 10.

Date:

Signature of Applicant:

Signature of Parent or Guardian (if applicant is under 18). I hereby consent to the issuance of the license/permit:

Date:

 Parent

 Legal Guardian

Phone Number:

Email Address:

23 VSA §4 "Resident,"…means any person living in the State who intends to make the State his or her principal place of domicile either permanently or for

an indefinite number of years. Without limiting the class of nonresidents under the provisions of this subdivision, persons who live in the State for a particular

purpose involving a defined period of time, including students, migrant workers employed in seasonal occupations, and persons employed under a contract with

a fixed term, are not residents for purposes of this title only….

VL-21 50M 06/2016 MTC

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