Form Dl 1p - Driver'S License And Identification Card Application Page 2

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DL 1P (07/01/2016)

PARENT OR LEGAL GUARDIAN LICENSE CONSENT

Check applicable box, review certification statement, print your name and sign where indicated.

I authorize issuance of a learner's permit/driver's license

. I certify that the applicant is a resident of Virginia. I certify that the applicant is

attending school regularly and is in good academic standing, but if not, I authorize issuance of a learner's permit/driver's license. I certify that this applicant

will operate a motor vehicle for at least 45 hours (15 of which will occur after sunset) while holding a learner's permit.

If the applicant attends public school, I authorize the principal or designee of the public school attended by the applicant to notify the juvenile and domestic

relations district court (within whose jurisdiction the applicant resides) when the applicant has had 10 or more unexcused absences from school on

consecutive school days.

If a Special Indicator Request is checked on this application, I request on behalf of the applicant that it be shown on the learner's permit/driver's license.

I certify that the statements made and the information submitted by me are true and correct.

I authorize issuance of an ID card.

If the applicant is under age 18, I certify that the applicant is a resident of Virginia. If a Special Indicator Request is

checked on this application, I request on behalf of the applicant that it be shown on the identification card.

I certify that the statements made and the information submitted by me are true and correct.

PARENT/GUARDIAN NAME (print)

PARENT/GUARDIAN SIGNATURE

DATE (mm/dd/yyyy)

APPLICANT UNDER AGE 18

Have you ever been found not innocent of any offense in a Juvenile and Domestic Relations Court in this or any other state?

YES

If you answered YES, a court within your jurisdiction must provide court consent below.

COURT CONSENT

should be granted.

should not be granted.

In my opinion the applicant's request for a learner's permit/driver's license

REMARKS:

JUDGE NAME (print)

JUDGE SIGNATURE

DATE (mm/dd/yyyy)

SELECTIVE SERVICE

All males under the age of 26 are required to check one of the following. Failure to provide a response will result in denial of your application.

I am already registered with Selective Service.

I am a non-immigrant alien in the U.S. and not required to register.

I authorize DMV to forward to the Selective Service System personal information necessary to register me with Selective Service.

By signing this application, I consent to be registered with Selective Service, if required by federal law. If under age 18, an appropriate adult must complete and

sign below: I authorize DMV to send information to Selective Service which will be used to register applicant when he is 18 years old.

PARENT / GUARDIAN

JUDGE, JUVENILE DOMESTIC RELATIONS COURT

EMANCIPATED MINOR

SIGNATURE (check one and sign)

GOVERNMENT EMPLOYEES - (Fee waiver certification)

I certify that I am employed by the:

Commonwealth of Virginia or

City of

County of

Town of

to operate a motorcycle and, because of such employment, I am entitled to the waiver of the motorcycle class endorsement fee, provided I have paid for and hold

a valid Virginia driver's license or have made application for such.

NOTICE

Va. Code §§46.2-323 and 46.2-342 require that you provide DMV with the information on this form (including your social security number). This social security number is for record

keeping purposes and may be disseminated only in accordance with Va. Code §§46.2-208 and 46.2-209. Persons convicted of certain sexual offenses (as listed in Va. Code §9.1-902)

must register or re-register with the Virginia Department of State Police as provided in Va. Code §§9.1-901, 9.1-903, and 9.1-904. If you provide a non-Virginia residence/home

address or non-Virginia mailing address, your application for a driver's license or permit may be denied.

CERTIFICATION

I certify and affirm that I am a resident of Virginia, that all information presented in this application is true and correct, that any documents I have presented to

DMV are genuine, and that my appearance, for purpose of my DMV photograph, is a true and accurate representation of how I generally appear in public. I make

this certification and affirmation under penalty of perjury and understand that knowingly making a false statement on this application is a criminal violation.

DATE (mm/dd/yyyy)

APPLICANT NAME (print)

APPLICANT SIGNATURE