Application For License / Identification Card / Permit
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3LI-1
State of Rhode Island - Division of Motor Vehicles
Application for License / Identification Card / Permit
rev 09/10.1
USE BLUE OR BLACK INK ONLY
Page 1 of 2
Transaction Type (Please Select One)
LICENSE
IDENTIFICATION CARD
(complete sections A, B, C, D, H)
(complete sections A, B, C, E, H)
NEW
RENEW
DUPLICATE
UPDATE
OUT-OF-STATE
NEW
RENEW
DUPLICATE
UPDATE
PERMIT
(complete sections A, B, C, D, H)
MOTORCYCLE
(complete sections A, B, C, D, H)
PERMIT
DUPLICATE PERMIT
LICENSE
NEW
RENEW
DUPLICATE
UPDATE
AFFIDAVIT OF LOST LICENSE, ID or PERMIT
COMPUTERIZED KNOWLEDGE EXAM (Circle one language)
(complete sections A, B, C, F, H)
VOLUNTARY TERMINATION OF A LICENSE AFFIDAVIT
ENGLISH
SPANISH
PORTUGUESE
(complete sections A, B, C, G, H)
A.
Applicant’s Information (Complete All Fields)
LAST NAME:
FIRST NAME:
MIDDLE NAME:
SUFFIX:
DATE OF BIRTH:
GENDER:
(MM/DD/YY)
SOCIAL SECURITY NUMBER:
MALE
FEMALE
RI DRIVER’S LICENSE # / R.I. ID # / PERMIT #:
PASSPORT / EMPLOYMENT AUTHORIZATION / RESIDENT ALIEN CARD #:
STREET ADDRESS:
CITY/TOWN:
STATE:
ZIP:
RESIDENCE ADDRESS
STREET ADDRESS:
CITY/TOWN:
STATE:
ZIP:
MAILING ADDRESS (IF DIFFERENT FROM RESIDENCE ADDRESS)
ACTIVE
DISABLED
TELEPHONE:
YES
NO
YES
NO
MILITARY:
VETERAN:
(
)
B.
Place Of Birth (Complete All Fields)
CITY:
STATE/PROVINCE:
COUNTRY:
C.
Physical Information (Complete All Fields)
HEIGHT:
WEIGHT:
EYE COLOR:
HAIR COLOR:
ft/in
lbs
(Circle one)
(Circle one)
BROWN
GREEN
GRAY
DICHROMATIC
BLACK
BROWN
WHITE
BALD
BLUE
BLACK
HAZEL
PINK
BLONDE
RED
GRAY
D.
License/Permit/Knowledge Exam Questions
1.
Are you a Rhode Island resident?
7.
Are you a US Citizen?
YES
NO
YES
NO
Is your license or right to operate a vehicle currently
2.
YES
NO
Do you want to be an Organ Donor?
8.
YES
NO
suspended, revoked, or refused by this or any other
state?
9.
Do you want to Register to Vote?
YES
NO
3.
Do you have any conditions (other than eyesight)
(Applicable to only U.S. citizens)
YES
NO
that could impair your ability to drive a motor vehicle?
If you are 18 years old on or before Election Day you
If yes, list any: _________________________________
may register. If you are at least 16 years of age, you
may pre-register.
4.
Have you ever been convicted of a motor vehicle
YES
NO
List your party affiliation or print Unaffiliated:
offense in District or Superior Court?
If yes, please explain: __________________________
________________________________________
____________________________________________
NOTICE TO MALES 18 TO 26 YEARS OF AGE:
5.
Do you use any type of corrective lenses while driving?
YES
NO
Pursuant to RI Gen. Laws 31-10-47(a), “(a)ny male, United States citizen
or immigrant who is at least eighteen (18) years of age, but less than
TO BE COMPLETED BY OUT-OF-STATE TRANSFERS ONLY
twenty-six (26) years of age shall be registered in compliance with the
YES
NO
Have you ever held a license in any other state?
6.
requirements of section 3 of the "Military Selective Service Act",
50 U.S.C. App. 451 et seq., when applying to receive a driver's license,
If yes, what is the most recent state? ____________
renewal or identification card or renewal.”
License Number:______________________
Exp. Date: _____________
Pursuant to RI Gen. Laws 31-10-47(b), the applicant recognizes that by
Endorsements: _______________________________
submitting this application he is consenting to registration with the
Restrictions: _________________________________
Selective Service system, if so required by federal law.
CONTINUED ON BACK
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