Application For A Driver'S License Or Identi Cation Card Page 2

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TYPE OF LICENSE / ID APPLICANT WISHES TO OBTAIN

Any valid license / ID issued by any jurisdiction must be surrendered.

* Only one state issued Driver’s License or ID card per person may be designated “For Federal Identi cation”. If you choose this option you will receive a temporary license or ID card for use until you permanent card arrives in

approximately ten (10) business days through UPS.

PHYSICIAN / AUDIOLOGIST CERTIFICATION FOR MEDICAL ENDORSEMENT

* Only one state issued Driver’s License or ID card per person may be designated “For Federal Identi cation”. If you choose this option you will receive a temporary license or ID

card for use until you permanent card arrives in approximately ten (10) business days through UPS.

I certify that the applicant named herein is

diabetic

deaf

hard of hearing.

PHYSICIAN / AUDIOLOGIST CERTIFICATION FOR MEDICAL ENDORSEMENT

SIGNATURE (Physician for diabetic or audiologist for deaf/hard of hearing)

MEDICAL LICENSE NUMBER

STATE

I certify that the applicant named herein is

diabetic

deaf

hard of hearing.

ADDRESS

BUSINESS PHONE NUMBER

AFFIDAVIT OF WEST VIRGINIA RESIDENCY

Homeowner Information and Certi cation

SIGNATURE (Pysician for diabetic or audiologist for deaf/hard of hearing)

MEDICAL LICENSE NUMBER

STATE

hereby swear or a rm that

FULL NAME OF APPLICANT

FULL NAME OF HOMEOWNER

resides in my home at the following address:

ADDRESS

BUSINESS PHONE NUMBER

STREET ADDRESS

CITY

STATE

ZIP CODE

SIGNATURE OF HOMEOWNER

WV DRIVER’S LICENSE/ID NUMBER

DATE

Males age 18 - 25 only: I understand that I am required to register for the military draft and that my information will be forwarded to the Selective Service System, as required by law.