Form 447 - Application For S.c. Credential

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South Carolina Department of Motor Vehicles

447

Form

(Rev. 10/06)

Application for S.C. Credential

BEGINNER PERMIT/DRIVER LICENSE/IDENTIFICATION CARD NUMBER

CUSTOMER NUMBER

I AM APPLYING FOR A (check any that apply):

Beginner’s

Driver’s

Commercial

Commercial Driver’s

Identification

Moped

Permit

License

Card

Beginner’s Permit

License

MIDDLE NAME

SUFFIX

FIRST NAME

LAST NAME

RESIDENCE ADDRESS (Must be your current address of residence and cannot be a P.O. Box)

City or Town

State

Zip Code

County

I understand the Department will send mail to the residence address above

unless I have specified a special or temporary mailing address below.

SPECIAL MAILING ADDRESS - Optional (To have your mail sent to an address different from residence address)

County

State

Zip Code

City or Town

Do you want to delete a current special mailing address now on file?

Yes

_______________

TEMPORARY MAILING ADDRESS - Optional (To have your mail sent to an address for a limited time period)

Expiration Date

State

City or Town

Zip Code

County

Do you want to delete a current temporary mailing address now on file?

Yes

SOCIAL SECURITY NUMBER * (SSN)

SEX

DATE OF BIRTH

HEIGHT

WEIGHT

RACE

Month

Day

Year

Male

Female

Feet

Inches

*Your Social Security number is reqired for the purposes of identifying you and preparing jury lists pursuant to South Carolina Code of Laws Sections 56-1-90 and 14-7-130. The Driver’s Privacy Protection Act of 1994 (DPPA), 18 U

S.C. Section 2721,2725, the Family Privacy Protection Act of 2002 (FPPA), 30-2-10 et seq., and Section 56-3-545 of the S.C. Code restrict the disclosure of personal information contained in our records.

MOTOR VOTER (check one box)

Yes, I wish to complete a DMV Voter Registration Application.

*Must be a United States Citizen and meet age requirements to complete a DMV Voter Registration Application.

No, I am not eligible to vote

No, I have already registered to vote.

No, I decline the DMV Voter Registration Application.

ORGAN AND TISSUE DONATION (optional)

Yes, I want to be an organ and tissue donor. (A symbol will be added to your credential if you choose to be an organ donor.)

Yes, I wish to donate $1.00 or more to Donate Life South Carolina. Amount of donation $

.00

ALL OF THE FOLLOWING QUESTIONS MUST BE ANSWERED

Yes

1. Are you a resident of South Carolina?

Yes

2. Are you a citizen of the United States?

Yes

3. Do you now have or have you ever had a South Carolina beginner’s permit or driver’s license? If yes, give the number and name if different

from number and name given on this application_____________________________________________________________________

Yes

4. Do you have or have you had a learner’s permit or driver’s license from another state or country? If yes, list information from last time issued

State/Country _______________________ license number ______________________ and issue date _________________________.

Yes

5. Is your driver’s license or privilege to drive suspended, cancelled, revoked or disqualified in any state?

If yes, where?________________________________________________ When last?______________________________________.

Yes

6. Have you recently surrendered your license or beginner’s permit in court or to a law enforcement officer?

If yes, when?___________________________________________________ Reason_______________________________________.

Yes

7. In the past 12 months, have you experienced a loss of consciousness, muscular control or seizure?

Yes

8. a) In the past six months, have you experienced a heart attack or heart surgery?

Yes

b) Has your doctor recommended you not drive or placed restrictions on your driving at this time?

If the answer to “b” is yes, what are the restrictions?

Yes

9. Have you had a stroke and not recovered sufficiently to safely operate a motor vehicle at this time?

Yes

10. Are you a habitual user of alcohol or any other drug to a degree which prevents you from safely operating a motor vehicle at this time?

Yes

11. Do you have any mental or physical condition preventing you from safely operating a motor vehicle at this time?

If yes, please list condition(s):

Yes

12. Has your doctor recommended you not drive or placed restrictions on your driving at this time?

If yes, what are the restrictions?

NOTE: Section 23-3-460 of the S.C. Code of Laws states that a person who has been convicted anywhere of an offense listed in 23-3-430 must register with the county sheriff within 10 days

of establishing residency in South Carolina. A copy of the Sex Offender Registry Law is available upon request.