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Alaska DMV Form 478 Application for - …

state of alaska division of motor vehicles application for alaska driver license, permit or identification card (rev.08/14/2017) alaska.gov/dmv

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Text of Alaska DMV Form 478 Application for - …

STATE OF ALASKA DIVISION OF MOTOR VEHICLES APPLICATION FOR ALASKA DRIVER LICENSE, PERMIT OR IDENTIFICATION CARD ( ) FULL LEGAL NAME: First Middle Last Suffix AK license / permit / ID number, if applicable. Date of Birth Sex Height ft in Weight Hair Color Eye Color PLACE OF BIRTH: City State Country (If other than USA) Social Security Number Mailing Address (This address will appear on the license, permit or ID.) City State Zip Code Residence Address (Physical location no PO Box or Mail Receiving Station addresses.) City State Zip Code Email Phone # VETERANI declare myself an honorably discharged US Armed Forces veteran and authorize DMV to send my personal information to the Dept. of Military and Veterans Affairs to provide benefits to me. YES NO I have a US Armed Forces honorable discharge and wish to have a veteran designation placed / retained on my license. YES NO ORGAN DONORWould you like to be an organ donor with a designator displayed on your license / ID card? YES NO Would you like to donate $1 or more to the anatomical gift awareness fund? If so, how much? $ VOTER REGISTRATION Would you like to register to vote or make changes to your voter registration YES NOAre you a Citizen? You may not register to vote if you are not a citizen. YES NOHave been convicted of a felony? YES NOHave you been unconditionally discharged? YES NOWould you like your residence address kept confidential? (Your residence address must be DIFFERENT than your mailing address to be kept confidential.) YES NO If you are already registered to vote in the State of Alaska, this form will update your voter registration address. Do you want your address updated for voter registration purposes? (In order to be a registered voter of Alaska, you must provide an Alaska residence address.) YES NO PREVIOUS NAMES List any previous / maiden names by which you have been known: DRIVER LICENSE QUESTIONS (You do not need to answer these questions for an ID card)List any States in which you have ever held a permit, license or id card: Have your driving privileges ever been suspended or revoked or application for license refused? YES NO State: Date: Reason: State: Date: Reason: Within the past 5 years, have you had a medical condition or impairment, mental or physical disorder, seizure, or any other health problems that could affect your ability to safely operate a motor vehicle? YES NO If yes, please explain: Within the last five years, have you had three or more alcohol or drug related convictions? YES NO If yes, you must provide physician verification that the problem is under control or proof of completion of a rehabilitative treatment program COMMERCIAL DRIVERS ONLY Are you domiciled (permanent residence) in the State of Alaska? YES NO I acknowledge that receiving an Alaska Permit, License or ID card may cancel or invalidate any Permit, License or ID card from another state per the laws of that state. I have personally reviewed the information on this application and certify under penalty of perjury that to the best of my knowledge and belief the information on this application is true and correct. NOTE: Making a false statement in connection with this application may be punishable by a maximum penalty of $50,000 or five years imprisonment or both per AS X Signature of Applicant (MUST SIGN IN FRONT OF A DMV REPRESENTATIVE) Date LOGIN ID / Office Number *****DMV USE ONLY ***** VISION TEST With CL Left Both Right Vision Notes CDL Color Blind Test: LICENSE Orig Renew Duplicate Without CL 20/ 20/ 20/ Pass / Fail / Medical Card ISSUED Class:DOCUMENTS SEEN / OTHER NOTES478 LICENSE / PERMIT CLASSIFICATION ENDORSEMENTS Driver License Non-Commercial (D) Hazardous Passenger (P) Instruction Permit Motorcycle Tank (N) School Bus (S) Identification Card CDL A B C Tank (N) + HazMat (H) Doubles / Triples

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