DMV-DS-23P REVISED 09/2021
YOU MUST ANSWER “YES” OR “NO” TO ALL QUESTIONS BELOW UNLESS YOU DO NOT MEET THE QUESTION’S CRITERIA.
West Virginia DMV
PO BOX 17010
Charleston, WV 25317
Name
Former Names
Residence Address
City, State, ZIP code
Mailing Address
WV License #
Gender
Birth date
Height
Eye Color
Do you wear corrective lenses?
Social Security Number
Daytime Phone (optional)
Application for a Driver’s License or Identication Card
Complete both sides of this application. All requested information is mandatory unless otherwise noted.
Weight
Has your address changed since your last License/ID issuance?
If “yes”, please list previous address below:
_____________________________________________________________________________
Please remember WV Law requires you to notify DMV within 20 days after a change of address.
Are you a U.S. Citizen? If not, list your Alien Registration Number below.
____________________________________________________________________________
Have you been issued a license/ID in another jurisdiction in the last 10 years?
If “yes”, list jurisdiction and License/ID#(s):__________________________
Do you have a suspended/revoked license or a pending license
suspension/revocation in ANY jurisdiction within the previous ve years?
If “yes”, you are required to provide a letter of explanation including the date of the incident.
Have you been refused a license by any jurisdiction within the previous
ve years?
If “yes”, you are required to provide a letter of explanation including the date of
the incident.
APPLICANTS THAT OWE A CHILD SUPPORT OBLIGATION ONLY: Do you
owe an obligation that is more than six months in arrears?
APPLICANTS THAT OWE A CHILD SUPPORT OBLIGATION ONLY: Are you
the subject of a child support-related warrant, subpoena, or court order?
LEVEL 2 GDL Applicants ONLY:
Have you been convicted of a trac
violation in the past six months?
LEVEL 3 GDL Applicants ONLY:
Have you been convicted of a trac
violation in the past 12 months?
Do you have any visual/medical condition(s) aecting your ability to
drive safely?
If “yes”, you are required to provide a letter of explanation.
Do you wish to be designated on your license as an organ donor?
By checking “yes”, you agree that the DMV may furnish your personal information to designated
organ donation groups.
Do you wish to be designated on your license as diabetic?
If “yes”, a
licensed physician must certify your condition by completing the MEDICAL ENDORSEMENT section
on side two of this application.
Do you wish to be designated on your license as hearing impaired?
If “yes”, a licensed audiologist must certify your condition by completing the MEDICAL ENDORSEMENT
section on side two of this application.
Veterans of the United States Military ONLY:
Do you wish to have the
United States Veterans designation on your license?
If you choose to have the
veterans designation, DMV is required to verify your status with your DD Form 214, WD AGO 53,
WD AGO 55, WD AGO 53-55, NAVPERS 553, NAVMC 78PD, NAVCG 553, Military Identication Card, or
a Current Military license plate registration card. (A CSR may verify status as a current military license
plate holder through the vehicle system if an applicant does not have their registration card on hand.)
Have you ever experienced seizures or loss of consciousness, emotional
or mental illness, alcohol or drug problems, or any physical condition
that requires you to use special equipment to drive?
If “yes”, you are required
to provide a letter of explanation.
Do you wish to make a contribution to the West Virginia State Police
Forensic Laboratory Fund?
If “yes”, specify the contribution amount: $
Do you wish to make a contribution to the West Virginia Department of
Veterans Assistance?
If “yes”, choose an amount:
�
$5
�
$10
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Other:
You must complete BOTH sides of this application. An incomplete application will not be processed.
YES NO
LAST, FIRST, AND MIDDLE
MM DD YYYY
LBS FT IN
SUPPORTING LEGAL DOCUMENTATION IS REQUIRED BY LAW
REQUIRED IF DIFFERENT FROM RESIDENCE ADDRESS
/
( ) -
Cellular Phone (optional)
( ) -
/
Email Address (optional)
County of Residence
YES NO
