2019 Identification Certification

IDENTIFICATION CERTIFICATION Complete the information below and return this form along with a photocopy of the front and back of your driver license or state-issued ID. If you do not have either of these forms of ID, please check the appropriate box below.

License or ID Number: __________________________________________ Issuing State: ________________________________________________ Issue Date: __________________________________ Expiration Date: ______________________________ *Document Number: ___________________________________________

*Applies to New York State issued licenses and IDs only. The 8 or 10-digit number on the lower right corner of your license, permit or non-driver ID, or on the back if it was produced after January 28, 2014. (See page 2 for sample documents.)

I am providing a photocopy of the front and back of my driver license or state-issued ID as requested.

I do not have a driver license or state-issued ID.

Signature: ___________________________________ Print Name: __________________________________ Date: _______________________________________

Sample Photo Documents Driver License, Learner Permit & Non-Driver ID (Over 21)

Driver License, Learner Permit & Non-driver ID (Under 21)

Enhanced Driver License, Learner Permit & Non-Driver ID (EDL)

On enhanced documents issued after 1/28/2014, the document number begins after 'IDUSA' and is on the back of the document.

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download