Form 40-5122 - Driver License/identification Card Application
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DRIVER LICENSE / IDENTIFICATION CARD APPLICATION
Type:
Driver License
Motorcycle
Instruction Permit
Identification Card
Travel Driver License
Travel Identification Card
You are required by A.R.S. §§ 28-3158(D)(5) and §§ 28-3165(F), under authority of 42 U.S.C. §§ 405(c)(2)(C) and
40-5122 R04/16
azdot.gov
§ 666 (a)(13)(A), to provide your Social Security Number. It will be used to verify your identity and to comply with
federal and state child support enforcement laws. It will not be used as your driver license or identification card number.
Social Security Number
Applicant Name (first, middle, last, suffix)
−
−
Residence Street Address
(Unit # / Apt #)
City
State
Zip
Mailing Address (if different from above)
(Unit # / Apt #)
City
State
Zip
Street
Mailing Which address do you want to appear on your license?
Sex
Weight
Height
Eye Color
Hair
Date of Birth
Male
Female
Current Driver License Number
Name on Current Driver License or ID (if different from above)
Class
State
Issue Date
Expiration Date
Operator
Motorcycle
Commercial (CDL)
Identification Card
Yes
No
Has your driving privilege ever been suspended, disqualified, canceled, denied or revoked?
States
Dates
Reasons
If Yes:
Yes
No
Is your driving privilege now suspended, disqualified, canceled, denied or revoked?
Yes
No
Do you have a license from more than one state or jurisdiction?
State
I am active duty military or family member.
My vehicle is registered in another state (indicate which state):
I am an out-of-state student or family member.
I want to show a medical alert condition on my license/ID (must submit physician or registered nurse practitioner statement).
I also want this alert maintained on my permanent computer record. (If not checked, when you reapply or request a duplicate, the alert
will not appear on your license/ID unless you resubmit a physician or registered nurse practitioner statement.)
I consent to the release of personal information contained in my driver license and vehicle record. I understand that this is not a one-time
consent that applies only to a specific individual or organization, but is instead a general consent that applies to all requests from any and all
individuals or organizations for any purpose, until revoked by me in writing. Consent for a vehicle record applies to all owners.
Yes
No
Do you have a physical, psychological or visual condition (other than wearing glasses or contact lenses), or alcohol/drug dependency
or are you taking any medications that could affect your ability to safely operate a motor vehicle? (driver license applicants only)
Please Explain
Yes
No
Have you ever been determined to be incapacitated by a court? (driver license applicants only)
Party Preference
Republican
Yes
No
Democratic
Are you a United States citizen who wishes to register to vote or update your existing voter registration?
Other
I want to be placed on the permanent early voting list and receive an early ballot by mail for each election I am eligible.
_________________
DONOR♥ I check this box to become an organ/tissue donor and join the DonateLifeAZ Registry. DONOR♥ will print on my license.
I am a U.S. Military veteran who was enlisted, drafted, inducted or commissioned to serve in the active military, naval, or air service and I was
not dishonorably discharged. I would like the word “VETERAN” printed on my license/ID. (Documentation Required)
All Applicants: I certify under penalty of perjury that the information above is true and correct. I understand that I must report a change of
address or name to MVD within 10 days. All Driver Applicants: I understand the laws, rules and regulations described in the Arizona Driver
License Manual, and that I must report to MVD in writing, within 10 days, any medical condition that develops or worsens that may affect
my ability to safely operate a motor vehicle.
Male Applicants Under 26: By submitting this application, I consent to registration with the Selective Service System if I am required to
register under federal law. If I am under 18, I understand that I will be registered as required by federal law when I become 18.
Voter Registration: I certify that I am not a convicted felon or my civil rights have been restored, and that I have not been adjudicated
incompetent. I certify that I am a United States citizen. Submitting a false voter registration is a Class 6 felony. Your decision to register to
vote or not, and where you submitted your application, will remain confidential.
Applicant Signature (If under 18, Legal Guardian Certificate on the back must be completed.)
Notary or MVD Agent Signature
Acknowledged before me this date.
Date
County
State
Commission Expires
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