Form Dmv 06-105 - Clp And Cdl Data Form printable pdf download

CLP AND CDL DATA FORM

Date of Birth

Social Security Number

COMPLETE INFORMATION BELOW – PLEASE PRINT

Month

Day

Year

LAST NAME

FIRST NAME

MIDDLE INITIAL

SUFFIX (JR,

SR, 1

, 2

)

CURRENT RESIDENTIAL ADDRESS REQUIRED

CITY

STATE

ZIP CODE

(Street address or Route and P.O. Box)

CURRENT MAILING ADDRESS

CITY

STATE

ZIP CODE

(If different from residential address)

COUNTY

HEIGHT

EYE

HAIR

NUMBER

GENDER

WEIGHT

COLOR

RACE

FT.

IN.

BLACK

AMERICAN INDIAN

OTHER

WHITE

ASIAN OR PACIFIC ISL

HISPANIC

I am a citizen of the United States and agree to provide valid documentary evidence of such as outlined in 60-4,144

(valid documentary evidence required on and after July 8, 2015) ..............................................................................................

__Yes

__No

I am not a citizen of the United States, but do have lawful status and agree to provide valid documentary evidence of

such as outlined in 60-4,144 ........................................................................................................................................................

__Yes

__No

Please answer questions A1 AND A2.

A1. I hereby certify that the commercial motor vehicle in which I take any driving skills examination is representative of

the type of commercial motor vehicle that I operate or expect to operate. ..........................................................................

__Yes

__No

A2. I certify that I am not subject to any disqualification under 383.51 or any license disqualification under State law, that

my license is not suspended, revoked or cancelled in this or any other State and that I do not have a driver’s license

from more than one State or jurisdiction. ............................................................................................................................

__Yes

__No

Choose one of the following categories that apply to you (use chart to assist you in choosing correct category).

A. Interstate – Non-Excepted: Subject to federal medical/vision requirements - must provide DMV with current

medical examiner’s certificate (card – NOT long form) and keep current with DMV. ....................................................

__Yes

__No

B. Interstate – Excepted: Subject to DMV medical/vision requirements – answer questions #5-#7 below

__Yes

__No

C. Intrastate – Non-Excepted: Subject to federal medical/vision requirements and when on-duty must have medical

examiner’s certificate on person – NOT required to provide DMV with current medical examiner’s certificate ...............

__Yes

__No

D. Intrastate – Excepted: Subject to DMV medical/vision requirements – answer questions #5-#7 below .........................

__Yes

__No

Answer question A3 OR A4.

A3. I certify that I have not held a license (commercial or non-commercial) from any other State in the last ten years ............

__Yes

__No

A4. I certify that I have held a license (commercial or non-commercial) from the following State(s) in the last 10 years

__Yes

__No

Please list State(s) and any AKAs while holding those licenses: ___________________________________________

______________________________________________________________________________________________

Please answer the following motor voter and veteran questions (answers are optional).

1A. Do you wish to register to vote as part of this application process? (You only need to re-register if you have changed

your name, address or political party ..................................................................................................................................

__Yes

__No

1A1. Party Affiliation: Republican _____ Democratic ____ Libertarian ____ Non Partisan (no party) ____

1A2. Last Registration Address City:_____________________________ County________________ or State_____

1B. Do you wish to have the word “Veteran” displayed on the front of your license to show that you served in the armed

forces of the United States? (To be eligible you must register with the Nebraska Department of Veterans’ Affairs

Registry ...............................................................................................................................................................................

__Yes

__No

Please consider the following organ and tissue donation questions.

Do you wish to include your name in the Donor Registry of Nebraska and donate your organs and tissues at the time

of your death? ......................................................................................................................................................................

__Yes

__No

Do you wish to receive any additional specific information regarding organ and tissue donation? ....................................

__Yes

__No

Do you wish to donate $1 to promote the Organ and Tissue Donor Awareness and Education Fund? ...............................

__Yes

__No

You must answer the following medical questions if you answered “Yes” to questions B or D above. DO NOT answer the following

questions if you answered “Yes” to questions A or C above.

Have you within the last three months (e.g. due to diabetes, epilepsy, mental illness, head injury, stroke, heart

condition, neurological disease, etc.):