Form Dl 5 - Identification Card Application For Minors Under Age 15

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Completion of this section is requested but not required to apply for a driver's license or ID Card. (Virginia Code §2.2-3806)
INFORMATION FOR THE VIRGINIA TRANSPLANT COUNCIL
Yes, I would like to become an organ, eye and tissue donor.
DL 5 (11/16/2017)
IDENTIFICATION CARD APPLICATION
LOG #
FOR MINORS UNDER AGE 15
Purpose:
Minors under age 15 use this form to apply for an identification card.
Instruction: To qualify for an identification card for a minor, the applicant must be a Virginia resident under age 15. Print in ink or type.
Virginia Code requires that you provide DMV with the information on this form (including your social security number).
APPLICATION TYPE
Original
If you are applying for a replacement ID Card check one the following;
Renewal
I am surrendering my current ID Card.
Replacement
I certify my current ID Card is unavailable for surrender because it is:
lost
stolen
destroyed/mutilated
APPLICANT INFORMATION
NOTE:
YOUR ADDRESS BELOW MUST BE CURRENT. THE U.S. POSTAL SERVICE WILL NOT FORWARD ID CARDS.
FULL LEGAL NAME (last, first, middle, suffix)
SOCIAL SECURITY NUMBER (SSN)
I HAVE NOT BEEN
ISSUED A SSN.
BIRTHDATE (mm/dd/yyyy)
GENDER (check one)
WEIGHT
HEIGHT
EYE COLOR
HAIR COLOR
LBS.
FT.
IN.
MALE
FEMALE
STREET ADDRESS
APT NO.
CITY
STATE ZIP CODE
TELEPHONE NUMBER (optional)
IF YOUR NAME HAS CHANGED, PRINT FORMER NAME HERE
NAME OF CITY OR COUNTY OF RESIDENCE
CITY
COUNTY OF
MAILING ADDRESS (if different from above - this address will show on your ID card)
APT NO.
CITY
STATE ZIP CODE
SPECIAL INDICATOR REQUEST
Please show the following indicator(s) on my ID card: (Must submit required physician statement.)
Insulin-dependent diabetic
Speech impairment
Hearing impairment
Intellectual disability (IntD)
Autism spectrum disorder (ASD)
EMERGENCY CONTACT INFORMATION
Participation in the Emergency Contact Program is voluntary. If you choose to participate, emergency contact information will be added to
your identification card record. This information will only be accessible to DMV and law enforcement. Add this information on page 2 of
this form.
"Certification" section on the back of this form must be completed.
FOR DMV USE ONLY — DO NOT WRITE BELOW THIS LINE
CUSTOMER NUMBER
TRANSACTION TYPE
REMARKS/PAID STAMP
FEE
ORIGINAL
REISSUE
DUPLICATE
RENEWAL
PROOF OF ID
PROOF OF RESIDENCY (primary)
PROOF OF SOCIAL SECURITY (specify)
PROOF OF RESIDENCY (secondary)
PROOF OF LEGAL PRESENCE (specify)
Document Type
Document Number
Expiration Date (mm/dd/yyyy)
Document Type
Document Number
Expiration Date (mm/dd/yyyy)
CSR SIGNATURE AND LOGONID
DOCUMENT VERIFIER SIGNATURE AND LOGONID

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