MICHIGAN DEPARTMENT OF STATE DRIVER LICENSE AND ID …
Customer: Please complete the area inside the black box by printing in ink.
MICHIGAN DEPARTMENT OF STATE DRIVER LICENSE AND ID CARD APPLICATION
Making a false statement on a driver license or ID card application can result in fines or criminal prosecution and action against your driving privilege.
Department personnel will notify law enforcement if they believe a fraudulent application is being made.
FULL LEGAL NAME (First)
(Middle)
ARE YOU A CITIZEN OF THE UNITED STATES?
(Last)
ARE YOU A RESIDENT OF THE STATE OF MICHIGAN?
RESIDENCE ADDRESS (Required)
CITY
IN THE LAST SIX MONTHS*, HAVE YOU HAD A MEDICAL
CONDITION WHICH AFFECTED YOUR ABILITY TO DRIVE?
ZIP
CHECK ONE:
MALE
COUNTY
FEMALE
DATE OF BIRTH (Month/Day/Year)
HEIGHT (FT/IN)
PHONE NUMBER/EMAIL
EYE COLOR
WEIGHT
MAILING ADDRESS CITY
STATE
ZIP CODE
NO
YES
NO
YES
(*Twelve months if applying for a chauffeur or commercial driver license.)
NO
IN THE LAST SIX MONTHS*, HAVE YOU HAD A FAINTING SPELL,
BLACKOUT, SEIZURE, OR OTHER LOSS OF CONSCIOUSNESS?
YES
(*Twelve months if applying for a chauffeur or commercial driver license.)
NO
IS YOUR DRIVER LICENSE CURRENTLY SUSPENDED, REVOKED,
CANCELLED OR DENIED IN MICHIGAN OR ANY OTHER STATE?
YES
WILL YOU BE OPERATING A MOTORCYCLE ON PUBLIC ROADS?
3/($6(&+(&.,) ................
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