Form Dmv-002 - Driver'S License, Driver Authorization Card, Or Identification Card Application Form Page 2
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1
2ALL APPLICANTS MUST COMPLETE THIS SECTION
Yes
No
1.
Have you ever had a driver’s license or identification card in another name? (If yes, complete question 1a) .....................................
(1a) Under what name was it issued? _______________________________________________________
2.
Have you ever had a driver’s license or identification card in another state? (If yes, complete question 2a) ......................................
(2a) Do you have the card in your possession? ................................................................................................................................
State _________ License Number ____________________Class/Type __________ Expiration Date
NOTE: The driver’s license or identification card application you’re submitting will cause any driving record from your previous state to be
transferred to Nevada. Due to your change of residency, the license or identification card in your previous state will show as surrendered. NRS
482.385 requires you to register each vehicle you own and operate now or within 30 days of becoming a resident. Initial: __________
3.
Has your driving privilege ever been revoked, suspended, canceled or denied? ................................................................................
If yes, State _________________ Date _________________ Reason ________________________________________
4.
Do you have any disability, illness, missing extremity, or take any medication that could affect your driving ability? ..........................
If yes, please explain
If you wish, some medical conditions may be indicated on your DL/DAC/ID. Form DLD7 must be completed by your physician.
5.
Would you like to be an organ donor and have that information indicated on your license or identification card? ...............................
NOTE: If you are at least 16 and less than 18 years old, a parent or guardian may sign the affidavit below to ensure your wishes are followed.
6.
Would you like to make a donation of $1 or more to the anatomical gift account? If yes, how much?
...............
7.
Would you like to register to vote or make changes to your current voter registration other than a change of address in the same ...
county? If yes, complete a separate Voter Registration Application. Application #: __________________________
8.
I declare myself an honorably discharged U.S. Armed Forces veteran and authorize the DMV to send my personal
information to the Department of Veterans Services to provide benefits information to me…………………………………………………
9.
I have a U.S. Armed Forces honorable discharge and wish to have a veteran designation placed/retained on my license………………
NOTE: If your card does not already have a veteran designation, you must present a copy of your DD-214.
10. If you are a male at least 18 years of age and less than 26 years old, would you like to register with the Selective Service? ............
By registering, you will remain eligible for federal student loans, grants, benefits relating to job training, most federal jobs
and, if applicable, citizenship in the United States. If YES, please initial here: ___________
Affidavits and Signatures Must Be Witnessed
By An Authorized DMV Representative
Initial
________AFFIDAVIT – CONSENT FOR MINOR’S LICENSE: I, the undersigned, do hereby consent to the issuance of an instruction
permit/license to _____________________________________, whose relationship to me is _______________________. I understand that I can
be held responsible for any liability caused by his/her negligence or willful misconduct in the operation of a motor vehicle (NRS 483.300 and/or
NRS 486.101). I understand that I may have the permit/license cancelled and be released from liability by signing a cancellation request at a DMV
Field Services Office. I also understand that before a license is issued, the minor may need to present a Certificate of Completion from a Nevada
DMV-approved Driver Education Course, and that I need to sign and submit a DLD-130, Beginning Driver Experience Log, to the DMV attesting
that he/she has completed at least 50 hours of behind-the-wheel driving experience.
_______ AFFIDAVIT – INSTRUCTION PERMIT: I, the undersigned, do hereby certify that I understand my instruction permit is valid for up to one
(1) year from date of issuance and I must carry it with me when I am driving. I understand the restrictions on my permit and agree to follow them.
_______ AFFIDAVIT – MINOR ORGAN DONOR: I, parent/guardian of minor applicant, understand that unless the anatomical gift is amended or
revoked by the donor before his/her death, I may not amend or revoke the anatomical gift. ____________________________________
Signature
_______AFFIDAVIT – NON-USE OF NEVADA DRIVING PRIVILEGE: I, the undersigned, do hereby certify that I have not operated any motor
vehicle since (date) __________________________________.
_______AFFIDAVIT – NO SOCIAL SECURITY NUMBER: I, the undersigned, do hereby certify that I have never been assigned a Social Security
Number under the provisions of the Social Security Act of the United States.
DISCLOSURE STATEMENT
The Privacy Act of 1974 is a federal law that authorizes use of your Social Security Number to verify identity. You are required to submit your
Social Security Number so the state may administer laws related to licensing drivers (NRS 483.290).
I hereby certify, under penalty of perjury, that all statements in this application are true and correct. I understand that any and all other
driver’s license or identification cards issued by any other jurisdiction will be surrendered upon issuance of a Nevada license or
identification card. I agree and understand that any misstatement of material facts may cause cancellation and/or denial of my license or
identification card under NRS 483.420 and NRS 483.530, respectively. I further understand that any misstatement of facts may be a
misdemeanor or felony under NRS 483.530 and may be punishable pursuant to NRS 193.130.
Applicant Signature
Date
Parent/Guardian Signature if Applicant is Under 18
DL/DAC/ID No.
Sworn Before Me This
Day of
, 20
Authorized DMV Representative ______________________________________________ Tech ID _________________
Signatures must be originals. Photocopies are not acceptable. Changes may not be made to this form once it is signed.
DMV-002 (Revised: 6/2014)
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