Form Mv3001 - Wisconsin Driver License (Dl) Application Page 3
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WISCONSIN DRIVER LICENSE (DL) APPLICATION
MV3001
12/2013
Ch. 343 Wis. Stats.
Wisconsin Department of Transportation
ALL APPLICANTS – Please Print
Social Security Number
Applicant Name – First, Middle, Last
(mm/dd/yyyy)
Birth Date
Residence Address – Street
Apt #
City
State
ZIP Code
County of Residence
Mailing Address – ONLY IF DIFFERENT from Residence
Apt #
City
State
ZIP Code
County of Residence
Sex
Race
Eyes
Hair
Height
Former Name (if changed since last license or ID card)
Weight
Reason for Name Change
1. Do you wish to register to be an organ and tissue donor?
YES
Marriage Divorce Other List:
Will you donate $2 to organ, tissue and eye donation efforts?
YES
2. OPT OUT - Do you wish to have your name and address
6.
Do you need glasses or contact lenses
YES
NO
YES
for driving?
withheld from lists WisDOT sells?
7.
In the past year have you had a loss of
YES
NO
3. Has your license, ID card or operating privilege ever been
YES
NO
consciousness or muscle control caused
revoked, suspended, cancelled, disqualified or denied?
by any of the following conditions?
If yes, list date and place:
If yes, check condition(s) and list date(s):
Seizure
4. Have you been convicted of operating while intoxicated
Traumatic Brain
Muscle or
YES
NO
or Head Injury (2)
Disorder (4)
Heart (6)
Nerve (2)
OUTSIDE of Wisconsin?
If yes, give date and place:
Stroke (2)
Diabetes (5)
Lung (7)
Mental (3)
5.
Do you hold a valid driver license/identification card
8. Check ONLY ONE of the following three boxes.
YES
NO
FROM ANOTHER STATE/COUNTRY?
I certify that I am a:
If yes, list:
U.S. Citizen
Permanent or Conditional Permanent Resident
Years of licensed driving experience in the United States,
Temporary Visitor
its territories and Canada. List:
I certify that the information on this application is true under penalty
9. I am a veteran registered with WDVA and wish to
YES
of perjury and I am a resident of Wisconsin.
(s. 343.14(5) Wis. Stats.)
have my veteran status indicated on my driver license.
(DMV is required to verify your status with WDVA.)
X
(Applicant Signature)
(Date)
OFFICE USE ONLY
Reason for Reissue:
Processor ID
Product Type
Date
REGI CDLI
CYCI SPRI JUVI MPDI
REAL ID
Wisconsin or Out-of-State License Number
State
Expiration Date
PROB RGLR OCCL SPRR JUVP NON
Legal Presence
Name/DOB Proof
Identity/SS Proof
Residency Proof
Application Type
ORG
RNW
DUP
REI
RSM
AMD
COA
Hearing (CDL Only) Driver Education
Class(es) Issued
P
C
A
B
C
D
M
Behind The Wheel School Name
School ID
Endorsements
H
N
P
S
T
F
Examiner ID
Skill Test Score
Highway Signs
Federal Medical Certificate Shown
Knowledge
YES
Expires:
NO
Payment
Amount
Acct.
$
Check
Cash
CC
X
(Processor Signature)
(Processor ID)
Check if vision section completed by DMV Examiner
VISION
Recommended Restrictions or Comments, or Indicate (NONE):
Temporal Field of
Visual Acuity
Without RX
With RX
Vision In Degrees
Right Eye
20/
20/
Being duly licensed to practice
Optometry Medicine, In Wisconsin, or Other
Left Eye
20/
20/
Corrective lenses required while driving
Color Perception
Name of State or Country
YES NO
Normal
Deficient
Progressive eye disease or cataracts
If Yes, to Progressive eye disease
I certify that the findings are correct
YES NO
one eye both eyes
or cataracts
and I examined this applicant on: __________________________
(Exam Date)
Describe:
X
(Eye Examiner Signature)
(License #)
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