Duplicate Driver License Application Form
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1Michigan Department of State Out-of-State Resident
Duplicate Driver License Application
Clear Form
Applicant Instructions
Please complete all sections below and sign your name on the signature line at the bottom of this application.
**Michigan Driver License Number (If available)
Date of Birth**
NAME (First, Middle, Last)
STREET ADDRESS (Michigan Residence)
CITY
STATE
ZIP CODE
MI
DAYTIME TELEPHONE NUMBER
(
)
**Applicant’s Out-of-State Mailing Address**
NAME (FIRST, MIDDLE, LAST)
STREET ADDRESS (OUT-OF-STATE MAILING ADDRESS)
CITY
STATE
ZIP CODE
EXTENSION NEEDED (Circle one) - A hard copy of your driver license will take approximately 10 business days to arrive
after processing. A temporary extension provides you with something to drive on until the hard copy arrives.
YES
NO
**FEES DUE: Check one.
Operator
$ 9.00
Chauffeur
$18.00
Enhanced Operator
$24.00
Enhanced Chauffeur
$33.00
My signature below certifies that all statements on this application are true and correct. I certify I am
a resident of the State of Michigan. IT IS A CRIME TO MAKE A FALSE REPRESENTATION ON AN
APPLICATION FOR AN OFFICIAL STATE OF MICHIGAN DRIVER LICENSE.
**
X__________________________________________________________
_____/_____/_____
Signature of Applicant / Adobe software signatures are not accepted.
Date
**PAYMENT METHOD:
Check one.
Check or Money Order payable to the State of Michigan: Mail with completed application to:
Michigan Department of State
Special Services Branch
7064 Crowner Drive
Lansing, MI 48918
You may fax this completed application to: 517-322-5438
Credit Card:
.
VISA
MasterCard
Discover
Name on Credit Card (Please Print) _______________________________________________________
Credit Card Number: ___________/__________ /__________/__________:
Expiration Date: _______/______
Month
Year
My signature below authorizes the Michigan Department of State to charge my account for the duplicate
driver license fee.
X__________________________________________________________
_____/_____/_____
Signature of Card Holder / Adobe software signatures are not accepted.
Date
OSRS-DRIVER (04/16)
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