Form Dld6a - Ut License Application Form
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1
2DLD Office Use Only:
UT LICENSE #
UT ID #
$15 LERN
ORG LERN
Last Name
Date of Birth
DPC
DL
CDL
ID
IDD
First Name
SSN or ITIN
LTID
LTDL
LTCDL
MVP
This info will not show on your DL or ID
Middle
Phone
Class:
A
B
C
D
Suffix
Gender
Email
Select
Endorsement:
H
N
X
Z
P
S
T
M
Visual Acuity:
Passed
Eye Statement
UT Residence Address
Restrictions:
A
B
K
L
G
V
6
J:___
City
Zip Code
Motorcycle Restrictions:
0
2
3
5
Mailing Address
Testing:
Written
Road
Refugee/Asylee
City
State
Zip Code
Station:______
Emp #:_______
Initials:_______
Select
Select
Height
Weight
NAME CHANGE
FT.
IN.
Hair Color
Eye Color
From:________________
To:___________________
Applicant’s
Mother’s
Place of
Maiden
ID #1:________________
ID #2:________________
Birth
State/Country
Name
Last
First
Legal Presence:________________________________
NOTICE: APPLICANT MUST ANSWER ALL QUESTIONS. FAILURE TO TRUTHFULLY COMPLETE
QUESTIONS MAY RESULT IN WITHDRAWAL OF DRIVING PRIVILEGE OR IDENTIFICATION CARD.
BC NAME
YES
NO
Are you a U.S. Citizen?
Full Legal Name:________________________________
YES
NO
Are you a legal permanent resident alien or a U.S.
National?
DOB:____/____/____
Iss. Date:____/____/____
YES
NO
If you are a citizen of another country, do you have
evidence of lawful presence in the United States?
BC PP DHS #:_________
Iss. Agency:___________
YES
NO
I would like to register my desire to be an organ, eye, and tissue donor
(lifesaving anatomical gift.)
Required Docs Scanned Date:_____________________
YES
NO
Are you a U.S. Military Veteran?
YES
NO
If yes, do you authorize sharing this information with the Utah Division of
SSN, ADDRESS, SAVE
Veterans Affairs for the purpose of identifying veterans and disseminating
veteran benefit information?
SSN:____-____-____
Date:_________________
YES
NO
If you have been honorably discharged from the U.S. Military, would you like
to have a VETERAN indicator on your driver license or ID card?
SSV:
Yes / Override
Date:_________________
YES
NO
Are you required to register as a sex offender with the State of Utah, any
other state, or with the U.S. Government?
Address Verified Date:__________
If you are not registered to vote where you live now, would you like to
YES
NO
register to vote today? (U.S. Citizens Only)
nd
rd
SAVE:
2
:__________
3
:__________
YES
NO
If you are 16 or 17 years of age, and will not be 18 years of age before the
date of the next election, would you like to preregister to vote today?
Approved Final Date:__________
Exp.:__________
YES
NO
Do you now have, or have you ever been issued, a driver license by another
state, country or province? If yes, list states/countries/provinces:
Denied Date:__________
Employee #:___________
____#_________Exp. Date______
____#_________Exp. Date______
YES
NO
If you are a CDL driver, have you been licensed in another state within the
CDL
last 10 years? If yes, please list:
____#_________Exp. Date______
____#_________Exp. Date______
CDLIS
CSR
CDR
YES
NO
In the last 10 years, has your driving privilege been suspended, revoked,
canceled, denied or disqualified? If yes, State:____ #________________
SI:__________
SI:__________
SI:__________
Why_______________________________________________________
YES
NO
Are you required to carry a medical certificate (DOT Card?) If yes, are you in
UA:__________
CSR:__________
compliance? ____________ Certificate expires: _________________
YES
NO
Do you wish to contribute a $2.00 donation to the “Friends for Sight” fund?
Match
No Match
Eligible
Not Eligible
YES
NO
Do you wish to contribute $2.00 to educate people about organ, eye and
tissue donation?
Pending
Error
License
YES
NO
Do you wish to contribute a $1.00 donation to the “Mobility Assistance
Fund?”
PDPS
YES
NO
Do you claim to be disabled under the Americans with Disabilities Act?
YES
NO
Do you claim to be indigent and are applying for an ID card for voting
SB:__________
License Surrender: Y / N
purposes?
CDL: Y / N
10-Year History: Received / Completed
Print the name of the person signing for minor:
Issued:__________
Expired:__________
State:_____
Endorsement:___
License #:________
Father
Mother
Guardian
ID Card
Lapsed
License Fee
$__________
Total $ ____________
Original
Lapsed 65
Reinstate Fee
$__________
Transaction # ______
Provisional
Upgrade
Admin Fee
$__________
Initials: ___________
$15 Learner Permit
Upgrade Previous Lic
ID Fee
$__________
DLD6a Rev. 5/15
Renewal
Downgrade
Charity Fee(s)
$__________
Cash
Check
Renewal 65
Retest Fee
Credit/Debit Voucher
Duplicate
MVP
Other
$__________
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