Form 478 - Application For Alaska Driver License, Permit Of Identification Card - Division Of Motor Vehicles

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STATE OF ALASKA

DIVISION OF MOTOR VEHICLES

APPLICATION FOR ALASKA DRIVER LICENSE,

PERMIT OR IDENTIFICATION CARD

LICENSE / PERMIT

CLASSIFICATION

ENDORSEMENTS

478

 Driver License

 Non-Commercial (D)

 Hazardous

 Passenger (P)

 Instruction Permit

 Motorcycle

 Tank (N)

 School Bus (S)

 Identification Card

 A

 B

 C

 Doubles / Triples

CDL

Tank (N) + HazMat (H)

FULL

First

Middle

Last

Suffix

LEGAL

NAME:

AK license / permit / ID number, if applicable.

Date of Birth

Sex

Height

Weight

Hair Color

Eye Color

PLACE

City

State

Country (If other than USA)

Social Security Number

BIRTH:

Mailing Address (This address will appear on the license, permit or ID.)

City

State

Zip Code

Residence Address (Physical location – no PO Box or Mail Receiving Station addresses.)

City

State

Zip Code

Phone #

I declare myself an honorably discharged US Armed Forces veteran and authorize DMV to send my personal information to the

 YES

 NO

VETERAN

Dept. of Military and Veterans Affairs to provide benefits to me.

 YES

 NO

I have a US Armed Forces honorable discharge and wish to have a veteran designation placed / retained on my license.

 YES

 NO

Would you like to be an organ donor with a designator displayed on your license / ID card?

ORGAN DONOR

Would you like to donate $1 or more to the anatomical gift awareness fund? If so, how much?

 YES  NO

Would you like to register to vote or make changes to your voter registration

 YES  NO

Are you a U.S. Citizen? You may not register to vote if you are not a U.S. citizen.

 YES  NO

Have been convicted of a felony?

 YES  NO

VOTER

Have you been unconditionally discharged?

REGISTRATION

 YES  NO

Would you like your residence address kept confidential? (Your residence address must be DIFFERENT than your mailing

address to be kept confidential.)

If you are already registered to vote in the State of Alaska, this form will update your voter registration address.

 YES  NO

Do you want your address updated for voter registration purposes?

(In order to be a registered voter of Alaska, you must provide an Alaska residence address.)

List any previous / maiden names by which you have been known:

NAMES

List any States in which you have ever held a permit, license or id card:

 YES

 NO

Have your driving privileges ever been suspended or revoked or application for license refused?

DRIVER

State:

Date:

Reason:

LICENSE

State:

Date:

Reason:

QUESTIONS

Within the past 5 years, have you had a medical condition or impairment, mental or physical disorder, seizure, or any other

 YES

 NO

(You do not need to

health problems that could affect your ability to safely operate a motor vehicle?

answer these

questions for an ID

If yes, please explain:

card)

 YES

 NO

Within the last five years, have you had three or more alcohol or drug related convictions?

If yes, you must provide physician verification that the problem is under control or proof of completion of a rehabilitative treatment program

COMMERCIAL

Are you domiciled (permanent residence) in the State of Alaska?

 YES

 NO

DRIVERS ONLY

I acknowledge that receiving an Alaska Permit, License or ID card may cancel or invalidate any Permit, License or ID card from another state per the laws of that state. I have personally reviewed the

information on this application and certify under penalty of perjury that to the best of my knowledge and belief the information on this application is true and correct. NOTE: Making a false statement in

connection with this application may be punishable by a maximum penalty of $50,000 or five years imprisonment or both per AS 11.46.505.

Date

AMVC ID / Office Number

Signature of Applicant (MUST SIGN IN FRONT OF A DMV REPRESENTATIVE)

*****DMV USE ONLY *****

LICENSE

Orig

Renew

Duplicate

VISION

With CL

Left