Form 735-173 - Application For Driving Privileges Or Id Card
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APPLICATION FOR DRIVING PRIVILEGES OR ID CARD
DMV
ORIGINAL
RENEWAL
REPLACEMENT
ENDORSEMENT
DRIVER LICENSE
INSTRUCTION PERMIT
ID CARD
AT-RISK
MOTORCYCLE
MC-3
FARM
CLASS C
ASS C RESTR'D
MC
APPLICANT INFORMATION:
NOTE: YOUR ADDRESS BELOW MUST BE CURRENT. THE U.S. POSTAL SERVCIE WILL NOT FORWARD YOUR LICENSE OR ID CARD.
LAST NAME (PRINT NAME)
FIRST NAME
MIDDLE NAME
SOCIAL SECURITY NUMBER
APPLICANT’S PLACE OF BIRTH (CITY & STATE OR COUNTRY)
TELEPHONE NUMBER
MOTHER'S MAIDEN NAME
DRIVER / ID NUMBER
DATE OF BIRTH (M-D-Y)
(
)
RESTRICTIONS
HEIGHT
WEIGHT
SEX (CIRCLE)
HAIR COLOR
EYE COLOR
Do you want your license or ID card to show
YES
X
M
F
that you are an anatomical donor?
NO
FT.
IN.
LBS.
RESIDENCE ADDRESS
MAILING ADDRESS (IF DIFFERENT FROM RESIDENCE ADDRESS)
CITY, STATE, ZIP CODE
CITY, STATE, ZIP CODE
CURRENT OR PREVIOUS MILITARY SERVICE: By checking this box I authorize DMV to send my name and address to the
Oregon Department of Veterans' Affairs (ODVA) for the purpose of receiving benefit information.
NOTE:
DRIVING HISTORY:
Have you ever had a driver license from another state, U.S. territory, or country?
If yes, what state or country:
Number (if known):
__________
1.
____________
YES
NO
2. Is your driver license currently suspended, cancelled or revoked?
YES
NO
3.
List other names you have used on a driver license or ID card. 1. __________________________________ 2. __________________________________
MEDICAL FITNESS:
Skip this section if applying for an Identification Card.
You are required to report any mental or physical condition or impairment that affects your ability to drive safely. You are not required to report all your
health conditions – only those that affect your ability to drive safely. DMV will use your answers to the following questions only for the purpose
of determining your eligibility for an Oregon driving privilege. If you have a condition or impairment that makes you unable to safely operate a motor
vehicle, you are not eligible for a driving privilege until you have provided additional medical information and/or passed DMV tests. If you answer “Yes”
to any one of the questions below, we will not be able to issue you a license at this time.
1.
YES
NO
2. Do you have any physical or mental conditions or impairments that affect your ability to drive safely?
YES*
NO
* If Yes: a) What is the condition or impairment?: ___________________________________________________________________________________
Describe how this affects your ability to drive safely: ________________________________________________________________________
3. Do you use alcohol, inhalants, or controlled substances to a degree that affects your ability to drive safely?
YES*
NO
* If Yes: Describe how your use affects your ability to drive safely: _________________________________________________
___________________
APPLICANT CERTIFICATION:
By signing this application, I certify that all documentation and information I provided to DMV is true and correct. I understand it is a crime to knowingly
make a false application for driving privileges or ID card. The offense is a class A misdemeanor and is punishable by jail time, a fine or both. DMV
will cancel and/or suspend my permit, driver license or ID if I make a false statement or present false documentation.
And applying for first driving privilege, applicant meets school enrollment requirements under ORS 807.066
I am a resident of or
IF under
or has a diploma or GED (proof of diploma or GED required).
domiciled in Oregon
18 years
And applying for first Class C license, applicant has completed driving experience requirements under ORS
as described in ORS
807.065(1)(2): 50 hours and Driver Education or 100 hours, or has a valid license from another state.
of age:
807.062
Signature of applicant’s mother or father whose parental rights have not been terminated or legal guardian.
SIGNATURE OF APPLICANT
X
X
SSN: Disclosure of your Social Security number (SSN) is mandatory for issuance, renewal or replacement of your driver license or identification card under ORS 807.021(1).
STOP - DO NOT WRITE IN THE AREA BELOW - FOR DMV OFFICE USE ONLY
OUTSTANDING REQUIREMENTS
TSR ID
VISION / HEARING
DATE RECEIVED
VISION:
HEARING:
OK
OK W/BIOPTIC
GOOD
LP or ADDRESS
DEAF
LENSES
OK/WCL
F OUTSIDE
G DAYLIGHT
REIN. FEE/SR-22
MIRROR
DRIVING ONLY
DATE
TSR ID
OTHER:
REFERRED:
ACUITY
F.O.V.
KNOWLEDGE TEST
DRIVE TEST
DATE STAMP
TEST
SCORE
TSR ID
DATE
CLASS
SCORE
TSR ID
1
DATE STAMP
TEST
SCORE
TSR ID
DATE
CLASS
SCORE
TSR ID
2
DATE STAMP
TEST
SCORE
TSR ID
DATE
CLASS
SCORE
TSR ID
3
DOCUMENTS PRESENTED
DOCUMENTS PRESENTED
DOCUMENTS PRESENTED
US BIRTH CERTIFICATE/PASSPORT/PASSPORT CARD
US BIRTH CERTIFICATE/PASSPORT/PASSPORT CARD
US BIRTH CERTIFICATE/PASSPORT/PASSPORT CARD
FOREIGN PASSPORT & DHS DOC. or ADMIT. STAMP
FOREIGN PASSPORT & DHS DOC. or ADMIT. STAMP
FOREIGN PASSPORT & DHS DOC. or ADMIT. STAMP
DHS DOCUMENT
DHS DOCUMENT
DHS DOCUMENT
OTHER (Specify) _________________________
OTHER (Specify) _________________________
OTHER (Specify) _________________________
LP=C
LP=P
LP=F
LP=U
LP=C
LP=P
LP=F
LP=U
LP=C
LP=O
LP=F
LP=U
DATE
TSR ID
2nd CHECK
DATE
TSR ID
2nd CHECK
DATE
TSR ID
2nd CHECK
DATE STAMP
FEE
TSR ID
$
735-173 (1-18)
STK# 300093
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