Form 4317-Mail-In Driver License Application-Missouri Department Of Revenue Driver License Bureau
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1
2OFFICE USE ONLY
MISSOURI DEPARTMENT OF REVENUE
FORM
DRIVER LICENSE BUREAU
PHONE: (573) 751-2730
RENEWAL
4317
P.O. BOX 200 JEFFERSON CITY, MO 65105-0200
MAIL-IN DRIVER LICENSE APPLICATION
DUPLICATE
(REV. 06-2010)
You may qualify to renew your driver license or obtain a duplicate driver license if you are active duty military personnel/dependent and are temporarily out-of-
state/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
NAME
MISSOURI DRIVER LICENSE NUMBER
SOCIAL SECURITY NUMBER
DATE OF BIRTH
__ __ __ - __ __ - __ __ __ __
_ _ / _ _ / _ _ _ _
MISSOURI ADDRESS
COUNTY
OUT-OF-STATE/COUNTRY MAILING ADDRESS
CITY
STATE
ZIP CODE
CITY, STATE, ZIP CODE, COUNTRY
__ __ __ __ __
HEIGHT
WEIGHT
EYE COLOR
SEX
WHEN WILL YOU RETURN TO MISSOURI?
__ __ __
PHONE
EMAIL
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
YOU MUST ANSWER ALL QUESTIONS THAT APPLY TO YOU
Y
Do you understand that any other driver license in your name is invalid with this application?
es
No
COMMERCIAL DRIVER LICENSE ONLY
I meet all requirements contained in the Federal Motor Carriers Safety Regulations, Part 391.
Yes
No
(Department of Transportation [DOT] medical card)
I am exempt from the requirements of the Federal Motor Carriers Safety Regulations, Part 391. (DOT medical card)
Yes
No
If “Yes”, mark whether you operate a commercial license in a state or federal exemption category.
State
Federal
Have you been licensed in any other state within the past 10 years?
Yes
No
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
ORGAN DONOR INFORMATION
Please review the attached information regarding the First Person Consent
Are you registered to vote?
Yes
No
Organ, Eye, and Tissue donor registry prior to answering the following questions.
Do you wish to register to vote?
Yes
No
Do you want to donate $1.00 to the organ donor fund?
Yes
No
(If so, a voter registration card will be mailed to you with your license. When you
receive it, you should mail it to the county clerk in the county where you reside.)
Do you authorize a symbol to be placed on your license
indicating your consent to be listed as an organ, eye, and
J88 NOTATION INFORMATION
tissue donor in the donor registry?
Yes
No
Are you deaf or hard of hearing, and wish to
BLINDNESS AWARENESS FUND INFORMATION
add the “J88” notation to your driver license?
Yes
No
Do you want to donate $1.00 to the
(If so, provide a doctor’s statement with this application.)
Blindness Awareness Fund?
Yes
No
BOATER IDENTIFICATION INDICATOR
Do you wish to add/retain a boater identification
CONCEALED CARRY WEAPON ENDORSEMENT (CCW) INFORMATION
indicator to your driver license?
Yes
No
Have you obtained a Missouri Concealed Carry Certificate of
If “Yes”, enter your Boating Safety Education Card control number
Qualification from the Sheriff or Sheriff’s designee
here___________ and add an additional $1.00 to your transaction.
in your Missouri county of residence?
Yes
No
PERMANENT DISABILITY INDICATOR
If “Yes”, do you wish to add or retain a CCW endorsement
Do you wish to add/retain a permanent disability
on the license produced for this transaction?
Yes
No
indicator to your driver license?
Yes
No
If “Yes”, submit a completed Form 5294 Physician’s Statement - Permanent
If “Yes”, enter the control number from the Concealed
Disability Indicator (available at dor.mo.gov) with this application.
Carry Certificate of Qualification here. #______________________
SELECTIVE SERVICE INFORMATION
APPLICANT’S SIGNATURE (SEE INSTRUCTIONS BELOW)
I HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT ALL INFORMATION
Do you wish to register with the Selective Service?
Yes
No
REGARDING THIS TRANSACTION, INCLUDING MY RESIDENTIAL ADDRESS
FURNISHED PURSUANT TO SECTIONS 302.171 AND 302.181 RSMo IS TRUE AND
MEDICAL (to be completed by applicant)
ACCURATE. (Signature must be centered in the box and not extend outside the box.)
In the past 6 months have you had:
SIGN IN THE BOX BELOW † † BLACK INK ONLY
SIGNATURE BOX
Convulsions, Epilepsy or Blackouts
Yes
No
Paralysis
Yes
No
Heart Attack, Stroke, Heart Disease
Yes
No
Other (If yes, please explain)
Yes
No
FOR THE PURPOSE OF SIGNING THIS FORM, A “POA” DESIGNATION
IS EQUIVALENT TO A DESIGNATION OF “ATTORNEY IN FACT”.
SIGNATURE BOX
MO 860-2508 (06-2010)
DOR-4317 (06-2010)
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