Fillable Form 4317 - Mail-In Driver License Application printable pdf download

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Missouri Department of Revenue

Form

4317

Mail-in Driver License Application

Office Use Only

Renewal

Duplicate

You may qualify to renew your driver license or obtain a duplicate driver license if you are active duty military personnel or dependent and are temporarily out-of-state

or country. Please complete this application and submit the required documents in order to receive a Missouri driver license through the mail.

Complete both sides of this application and answer all questions that apply to you.

Name

Missouri Driver License Number

Social Security Number

Date of Birth

__ __ __ - __ __ - __ __ __ __

_ _ / _ _ / _ _ _ _

Missouri Address

County

Out-of-State or Country Mailing Address

City

State

Zip Code

City, State, Zip Code, Country

__ __ __ __ __

Height

Weight

Eye Color

Sex

When will you return to Missouri?

__ __ __

Phone

Check one

Check the type of license you currently hold. (Mark only one.)

Military

Military Dependent

Class A

Class B

Class C

Class E

Class F

Class M

Do you understand that any other driver license in your name is invalid with this application?

Yes

Commercial Driver License Only

Any person applying for a commercial driver license (CDL) must certify to one of the four categories shown below in the Self-Certification Information block indicating the type of

commercial vehicle operation they drive in or expect to drive in with their CDL.

Drivers who select “non-excepted interstate” or non-excepted intrastate” below must also submit a current medical examiner’s certificate, and any applicable waivers, with this form.

I certify my commercial operating status is-check only one box below:

(Selecting more than one box will delay processing of this form.)

Non-excepted Interstate - (NI) Operates or expects to operate in interstate commerce and is subject to and meets the qualification requirements under 49 CFR part 391, and

is required to obtain a medical examiner’s certificate by 49 CFR 391.45. (Current medical examiner’s certificate, and any applicable waiver, must be submitted with this form.

Non-excepted Intrastate - (NA) Operates only in intrastate commerce and is required to meet Missouri’s current medical requirements. (Current medical examiner’s

certificate, and any applicable waiver, must be submitted with this form.)

Excepted Interstate - (EI) Operates or expects to operate in interstate commerce, but engages exclusively in transportation or operations excepted under 49 CFR 390.3(f),

391.2, 391.68, or 398.3 from all or parts of the qualification requirements of 49 CFR Part 391, and is not required to obtain a medical examiner’s certificate by 49 CFR

391.45. These exceptions are listed in detail on the Department of Revenue’s website at dor.mo.gov/faq/drivers/medcert.php.

Excepted Intrastate - (EA) Operates or expects to operate in intrastate commerce, but engages exclusively in transportation or operations that are excepted from all parts

of Missouri’s medical requirements. (This is Missouri’s grandfather exemption where the driver operates solely in intrastate commerce and had a valid chauffeur’s license

on or before May 13, 1988.)

Have you been licensed in any other state within the past 10 years?

Yes

If yes, please submit a list of those states, your license number, if known, and any alias names that you may have used while licensed in that state.

Motor Voter Information

J88 Notation

Are you registered to vote?

Yes

Are you deaf or hard of hearing, and wish to add the “J88” notation to you driver license?

Do you wish to register to vote?

Yes

(If so, provide a doctor’s statement with this application.)

(If so, a voter registration card will be mailed to you. When you receive it, you should mail

)

it to the county clerk in the county where you reside.

Organ Donor

Boater Identification Indicator

Please review the attached information regarding the First Person Consent Organ, Eye,

and Tissue donor registry prior to answering the following questions.

Do you wish to add or retain a boater identification indicator to your driver license?

Do you want to donate $1.00 to the organ donor fund?

Yes

Do you authorize a symbol to be placed on your license indicating your consent to be

If “Yes”, enter your Boating Safety Education Card control number here_________________

listed as an organ, eye, and tissue donor in the donor registry?

Yes

and add an additional $1.00 to your transaction.

Blindness Awareness Fund

Permanent Disability Indicator

Do you want to donate $1.00 to the Blindness Awareness Fund?

Yes

Do you wish to add or retain a permanent disability indicator to your driver license?

Yes

Applicant’s Signature (See Instructions Below)

If “Yes”, submit a completed Form 5294 Physician’s Statement - Permanent Disability

I hereby certify under penalty of perjury, that all information regarding this transaction,

Indicator (available at dor.mo.gov) with this application.

including my residential address furnished pursuant to Sections

302.171

and

302.181

Selective Service Information

RSMo is true and accurate. (Signature must be centered in the box and not extend outside

the box.) Sign in the box below. † Black ink only.

Do you wish to register with the Selective Service?

Yes

Signature Box

Medical (to be completed by applicant)

In the past 6 months have you had:

Convulsions, Epilepsy or Blackouts

Yes

Paralysis

Yes

Heart Attack, Stroke, Heart Disease

Yes

Other (If yes, please explain)

Yes

Signature Box

Form 4317 (Revised 10-2013)

Form 4317 - Mail-In Driver License Application

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