Mv3004 - Wisconsin Identification Card (Id) Application Page 2
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2WISCONSIN IDENTIFICATION CARD (ID) APPLICATION
(continued)
Wisconsin Department of Transportation
MV3004
All ID cards used for voting are FREE
Check the box
ID for FREE
Clear Form
APPLICANT – PLEASE PRINT
Applicant Name – First, Middle, Last
Birth Date
Social Security Number
(mm/dd/yyyy)
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
Weight
Height
Former Name (if changed since last license or ID card)
Reason for Name Change
1. Do you wish to register to be an organ, tissue and eye 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
5. Check ONLY ONE of the following three boxes.
YES
address withheld from lists WisDOT sells?
I certify that I am a:
U.S. Citizen
3. Do you hold a valid driver license/identification card
YES
NO
Permanent or Conditional Permanent Resident
FROM ANOTHER STATE/COUNTRY?
Temporary Visitor
If yes, list:
4. ID for FREE – I certify that I am a U.S. citizen,
6. I am a veteran registered with WDVA and wish to
will be at least 18 years of age by the next election
YES
have my veteran status indicated on my ID Card.
YES
and require a Wisconsin ID for free to vote.
(DMV is required to verify your status with WDVA.)
I certify that the information on this application is true under penalty of perjury and I am a resident of Wisconsin.
(s. 343.14(5) Wis. Stats.)
X
(Applicant Signature)
(Date – mm/dd/yyyy)
DONOR Check the box if you wish to help others by donating your organs, tissue and eyes upon your death. Your gift will be used
to save and improve lives through transplantation, research or education. If you are at least 18, checking the box indicates your legal
consent for donation. You do not have to answer this question to obtain an ID card.
OPT OUT Under Wisconsin open records laws, WisDOT must provide information from its records to requesters. If you do not want
your name and address included in requests we receive for ten or more records, you may ask WisDOT to withhold your name and
address from those lists by checking the box on the application.
Print
FOR MORE INFORMATION VISIT
OFFICE USE ONLY
Application Type
ORG
RNW
DUP
REI
RSM
REAL ID
Date
Processor ID
Payment
Amount
$
Check
Cash
CC
Acct.
Wisconsin or Out-of-State License Number
State
Expiration Date
Legal Presence
Name/DOB Proof
Identity/SS Proof
Residency Proof
X
(Processor Signature)
(Date)
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