Application For A Driver'S License Or Identi Cation Card
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2DMV-DS-23P REVISED 02/2017
Application for a Driver’s License or Identi cation Card
West Virginia DMV
PO BOX 17010
Complete both sides of this application. All requested information is mandatory unless otherwise noted.
Charleston, WV 25317
/
/
Name
WV License #
Birth date
LAST, FIRST, AND MIDDLE
MM
DD
YYYY
Former Names
Gender
Weight
Height
LBS
FT
IN
SUPPORTING LEGAL DOCUMENTATION IS REQUIRED BY LAW
Residence Address
Eye Color
Do you wear corrective lenses?
(
)
-
Mailing Address
Daytime Phone
(optional)
REQUIRED IF DIFFERENT FROM RESIDENCE ADDRESS
(
)
-
City, State, ZIP code
Cellular Phone
(optional)
Social Security Number
Email Address
(optional)
YOU MUST ANSWER “YES” OR “NO” TO ALL QUESTIONS BELOW, UNLESS YOU DO NOT MEET THE QUESTION’S CRITERIA.
YES
NO
YES
NO
Has your address changed since your last License/ID issuance?
Do you have any visual/medical condition(s) a ecting your ability to
If “yes”, please list previous address below:
drive safely?
If “yes”, you are required to provide a letter of explanation.
_____________________________________________________________________________
Do you wish to be designated on your license as an organ donor?
Please remember WV Law requires you to notify DMV within 20 days after a change of address.
By checking “yes”, you agree that the DMV may furnish your personal information to designated
O rgan
organ donation groups.
Are you a U.S. Citizen? If “no”, list your Alien Registration Number below.
D on o r
I n dic ato r
Do you wish to be designated on your license as diabetic?
If so, a
_____________________________________________________________________________
licensed physician must certify your condition by completing the MEDICAL ENDORSEMENT section
Have you been issued a license/ID in another jurisdiction in the last 10 years?
D i abe tic
on side two of this application.
I n d ic ato r
If so, list jurisdiction and License/ID#(s):___________________________
Do you wish to be designated on your license as hearing impaired?
Do you have a suspended/revoked license or a pending license
If so, a licensed audiologist must certify your condition by completing the MEDICAL ENDORSEMENT
Hearing
suspension/revocation in ANY jurisdiction within the previous ve years?
section on side two of this application.
Impaired
Indicator
If “yes”, you are required to provide a letter of explanation including the date of the incident.
Veterans of the United States Military ONLY: Do you wish to have the
Have you been refused a license by any jurisdiction within the previous
United States Veterans designation on your license?
If you choose to have the
ve years?
If “yes”, you are required to provide a letter of explanation including the date of
veterans designation, DMV is required to verify your status with your DD Form 214, WD AGO 53,
the incident.
WD AGO 55, WD AGO 53-55, NAVPERS 553, NAVMC 78PD, NAVCG 553, Military Identi cation Card, or
a Current Military license plate registration card. (A CSR may verify status as a current military license
VETERANS
APPLICANTS THAT OWE A CHILD SUPPORT OBLIGATION ONLY: Do you
DESIGNATION
plate holder through the vehicle system if an applicant does not have their registration card on hand.)
owe an obligation that is more than six months in arrears?
Have you ever experienced seizures or loss of consciousness, emotional
APPLICANTS THAT OWE A CHILD SUPPORT OBLIGATION ONLY: Are you
or mental illness, alcohol or drug problems, or any physical condition
the subject of a child support-related warrant, subpoena, or court order?
that requires you to use special equipment to drive?
If “yes”, you are required
to provide a letter of explanation.
LEVEL 2 GDL Applicants ONLY: Have you been convicted of a tra c
violation in the past six months?
Ages 18 and up ONLY: Do you wish to register to vote?
LEVEL 3 GDL Applicants ONLY: Have you been convicted of a tra c
violation in the past 12 months?
You must complete BOTH sides of this application. An incomplete application will not be processed.
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