Dmv-Vl021 - Application For Vermont Operator'S License, Junior Operator'S License Or Learner Permit
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1
2
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4Application for Vermont Operator’s License, Junior Operator’s License or Learner Permit
New
Renew
New
Renew
New
Renew
Learner Permit
Jr. Operator’s License
Operator’s License
Name:
Last
First
Middle
Mailing Address ( Street, Road or PO Box ):
City:
State:
Zip:
Physical Address:
City:
State:
Zip:
Social Security Number:
Date of Birth:
Place of Birth (City, State & Country):
The disclosure of your social security or federal identification number is mandatory, is solicited by the authority granted by 42 U.S.C. § §405(c)(2)(C) and/or 666(a)(13) and will be used by the
Department of Motor Vehicles in the administration of motor vehicle, tax and child support laws, to identify individuals affected by such laws.
Expiration date of previous
Vermont Driver
License/Permit No.
license or permit
ARE YOU A US CITIZEN? Yes No
Check if the above is a change to: Mailing address Physical address
IF “NO”, Do you have proof of legal presence? Yes No
Is the above a change of address for voting purposes? Yes No
First
M. I.:
Last
First
M.I.:
Last
Check if name has changed
(maiden name, etc).
Gender:
Eye Color:
Height:
Weight:
EDL?
*
EDL requires additional forms.
Male
Female
Yes
No
See Instructions on back.
Yes No
1
Do you need glasses or contact lenses when driving?
I understand that if I do not pass the
Yes No
2
Is your driving privilege revoked, restricted, suspended, or refused in any state?
required
eyesight
examination
to
Yes No
3
Do you now hold a valid license from another State? If yes, what state:
obtain my VT Learners Permit, JR
Operator, Operators License or EDL
Do you have a history of any physical or mental condition, other than properly corrected eyesight, that could
Yes No
4
within 30 days of the date of this
affect your ability to safely operate a motor vehicle? If yes, explain on back
application, and I have a valid license
N/A
Yes No
5
Do you wish to retain your motorcycle endorsement?
from another jurisdiction my privilege
Yes No
6
I certify that I am a Vermont Resident, as defined in Title 23 V.S.A. § 4
See back
to operate in Vermont will be
Yes No
suspended until such time as I pass the
7
Do you want to be, or continue to be, registered as an organ & tissue donor?
required examination.
Yes No
8
(Renewal Only): Does your current license contain a school bus endorsement?
Yes No
9
(Renewal Only): Are you requesting a photo renewal by mail?
Initial Here____________
See back
Signature of
Date:
Applicant:
I certify that the statements herein are true. This declaration made under penalties of 23 VSA § 202.
Guardian
Signature of Parent or Guardian
Date:
Parent
if applicant is under 18:
I hereby consent to the issuance of the license/permit:
AUDIT LINE:
PID ________________________
REST.____________________
RATER #
OPR NEW
16
PRINT (270)
CREATE 260
QCS
PDPS
QSD
OPR RENEW
17
NAME CHANGE (231)
220
225
DOB CHANGE (231)
222
227
OUT OF STATE LIC #
JUNIOR OPR
18
MISC CHANGE (231)
228
DOC LOC
PERMIT NEW
19
234
NNL PHOTO
POB SEX EYE HT WGT
MAILING ADD (232)
ENDORSEMENT
STATE
VOID
PERMIT RENEW
20
SS# CHANGE (232)
M
B
V
PHYSICAL ADD (233)
VISA
EXAM, FIRST
21
TEMP ISSUED
ADD CHG
DEL
ISSUE DATE
EXAM, SUBSEQ
22
PDPS HIT____________
TEMPORARY: VOID THIRTY (30)
EDL
($25.00)
33
DAYS FROM DATE OF ISSUE.
EXP DATE
TOTAL FEE
Plate
#
Examiner – Authorized Agent
INTERNET
TA-VL-21
06/2009 MTC
DMV Copy
Page 1
APPLICATION FOR ADDITION TO CHECKLIST
Notice to Applicant
By checking the boxes below I swear that:
If you were provided with this form when you applied for or renewed a motor vehicle
I am a citizen of the United States.
driver’s license, you may decline to register. If you decline to register; your failure to
I am a resident of Vermont at the address above.
register will remain confidential and will not be used for voter registration purposes. If
I will be at least 18 years old on or before the next election.
you are submitting this application in connection with a motor vehicle driver’s license
Check one box below:
application, or renewal, the office through which you submit this application will remain
I am at least 18 and I have taken the Voter’s Oath.
confidential and will be used only for voter registration purposes. Submission of a false
I am not yet 18 and will take the voter's oath after I am 18.
voter registration application is subject to the penalties of perjury as provided in 17
V.S.A. § 2011 and in 42 U.S.C. § 1973 gg – 10.
I hereby swear, or affirm under penalty of a $10,000 fine, or imprisonment for not more
than 15 years, or both, that the statements made by me in this application are true (as
VOTER’S OATH (Vermont Constitution, Chapter II, Section 42)
provided in 17 V.S.A. § 2011 and in 42 U.S.C. § 1973 gg –10).
Every voter must take the voter’s oath below before voting for the first time in
Vermont. You can attest for yourself that you have taken the oath or you can have
any person over 18 attest that you have taken the oath below:
__________________________________________
______________
You solemnly swear (or affirm) that whenever you give your vote or suffrage,
Signature (Required for Voter Registration Only)
Date
touching any matter that concerns the State of Vermont, you will do it so as in your
conscience you shall judge will most conduce to the best good of the same, as
DO NOT SIGN HERE EXCEPT TO REGISTER TO VOTE!
established by the Constitution without fear or favor of any person.
On the ________day of _____________, 20____, I certify that I took the Voter’s
Telephone (
)_____________________________
Oath myself OR the voter's oath was administered to me by a person over eighteen.
The last address at which I was registered to vote if any, was:
__________________________________________________________________
Signature of voter or person who administered the oath
Name:_________________________________________________________
For Town or City Clerk Use
Address:_______________________________________________________
On __________, 20____ the Town Clerk reviewed your application and
Give complete address,
____ ADDED ____ DID NOT ADD your name to the voter checklist. If not,
if outside Vermont, include County and State.
the reason was _____________________________________________________.
The applicant’s usual polling place is located at __________________________
Keep your copy of this application. Take the copy to the polls when you go to vote.
This is proof you submitted an application before the deadline for registration.
Signature of Town Clerk:
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