Driver Information

* All fields are required.

NOTE: Enter names below exactly as they appear on current license do not include suffix (Jr, Sr) if listed on your card.

Driver License Number

Last Four (4) Digits of Your SSN

First Name

Last Name

Do not include suffix (Jr., Sr.) if listed on your current license.

Email Address

Date of Birth

Vision Screening Requirements

Do you have a Vision Screening Approval Passcode?

Yes

No

Passcode

Enter the date of your Vision Screening

Vision test date must be within a year of the application date.

Please upload a copy of your Vision screening Form TC 94-202 completed by a credentialed medical specialist or vision specialist within the last year of exam.

Medical Questions

Have you suffered a seizure within the past 90 days?

Yes

No

Have you suffered any seizures or blackouts in the past three (3) years?

Yes

No

Last Seizure Date

Do you have any physical, mental, or emotional issues that would prevent you from operating a vehicle safely?

Yes

No

Do you have a license or ID revoked in any jurisdiction?

Yes

No

Jurisdiction Revoked In

(Select) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Northern Mariana Islands Puerto Rico U.S. Minor Outlying Islands U.S. Virgin Islands

I hereby certify that the information provided is true, accurate, and complete to the best of my knowledge.

Previous Next