N.w.t. Application For Driver'S Licence Or General Identification Card
ADVERTISEMENT
1
2N.W.T. APPLICATION FOR DRIVER'S LICENCE OR GENERAL IDENTIFICATION CARD
SECTION 1 - TRANSACTION REQUEST
I am requesting a:
Driver's Licence (DL) (first application)
Exchange/Transfer
Renewal
Downgrade
Upgrade
General Identification Card (GIC)
Replacement DL/GIC
Name, Address, or Gender Change
Re-instatement
SECTION 2 - DRIVER INFORMATION AND CITIZENSHIP
NAME:
Surname
Given 1
Given 2
Given 3
Given 4
HOME ADDRESS:
Street # & Name, Apt. #, Lot #, or description if applicable
Community
Postal Code
MAILING ADDRESS (If different from above):
Box #
Community
Postal Code
TELEPHONE / E-MAIL:
Home Telephone #
Work Telephone #
Cell Telephone #
E-Mail Address
PERSONAL INFORMATION:
DD/MM/YY
Date of Birth:
Gender:
M
F
Weight:
(kg.)
(lbs.)
Eye Colour:
Hair Colour:
Height:
(cm.)
(ft.in)
CITIZENSHIP:
I am a citizen of the following country (or countries, in case of dual citizenship):
Country #1
Country #2 (if applicable)
SECTION 3 - CONFIRMATION OF DRIVING HISTORY
Have you ever previously held a Northwest Territories Driver's Licence (DL)?
Yes
No
If yes, was it under another name?
Yes
No
If yes, what was the other name?
Previous name
Have you ever previously held a Driver's Licence (DL) from outside the Northwest Territories?
Yes
No
If "Yes":
Jurisdiction
Class
Endorsements / Conditions
DL Expiry Date
Has your DL been suspended or cancelled?
Yes
No
Do you have any pending suspensions?
Yes
No
If your previous licence has been suspended, cancelled, or has pending suspensions, please explain:
SECTION 4 - MEDICAL DECLARATION
Do you wear glasses or contact lenses
Have you ever had a stroke or mini-stroke?
Yes
No
for driving?
Yes
No
If yes, when?
Have you had a loss of consciousness
Have you ever had high blood pressure (170/110)?
Yes
No
within the past 10 years?
Yes
No
Do you suffer from a thyroid disorder?
Yes
No
Have you ever had a seizure?
Yes
No
Disorder:
Are you an insulin-treated diabetic?
Yes
No
Are you currently taking any medications which may
Have you ever had a heart problem?
Yes
No
impair your ability to safely operate a motor vehicle?
Yes
No
If yes, what kind?
List:
SECTION 5 - CHANGE OF NAME OR GENDER
My name has changed due to the following:
My gender has changed due to the following:
Divorce
Marriage
Legal Name Change
Other:
Medical Procedure
Other:
Supporting documents to be attached (Marriage Certificate, Divorce Decree, Legal Divorce Pending Letter, medical forms from physician)
SECTION 6 - CLIENT CONSENT TO RELEASE TO REGISTRAR
I certify that the information provided by me on this application is, to the best of my knowledge, correct. I consent to having any information
on this application or any document provided by me in support of this application verified by the Registrar of Motor Vehicles.
DD/MM/YY
X
Signature:
Date:
This information is being collected by the Department of Transportation for the purposes of motor vehicle records in accordance with the
Motor Vehicles Act and the Access to Information and Protection of Privacy Act . Questions about the collection of this information can be
directed to the Department's Access to Information and Protection of Privacy Coordinator.
Client ID #____________________
Issuer's signature ____________________ Medical Assessment Officer's Initials ________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business