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)
(Last)
RESIDENCE ADDRESS (Required)
COUNTY
CITY
ZIP CODE
CHECK ONE:
MALE
FEMALE
PHONE NUMBER
DATE OF BIRTH (Month/Day/Year)
EYE COLOR
HEIGHT (FT/IN)
WEIGHT
WOULD YOU LIKE YOUR NAME ADDED TO THE ORGAN DONOR
REGISTRY?
YES
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
NO
NO
YES
WILL YOU BE OPERATING A MOTORCYCLE ON PUBLIC ROADS?
NO
IN THE LAST SIX MONTHS*, HAVE YOU HAD A MEDICAL
CONDITION WHICH AFFECTED YOUR ABILITY TO DRIVE?
YES
(*Twelve months if applying for a chauffeur or commercial driver license.)
NO
YES
ARE YOU A CITIZEN OF THE UNITED STATES?
NO
PERMANENT MAILING ADDRESS (If different from residence)
YES
ARE YOU A RESIDENT OF THE STATE OF MICHIGAN?
MAILING ADDRESS CITY
STATE
ZIP CODE
I certify under the penalty for perjury that I am a legal Michigan resident, the statements made on this application are true, and that a court is not holding my license.
X SIGNATURE OF APPLICANT
NO
DATE (Month/Day/Year)
*** (THE SECTIONS BELOW ARE FOR DEPARTMENTAL USE ONLY)***
APPLICATION TYPE (Circle one)
TIP
ORIG.
REN.
DUP.
CORRECTIVE LENS?
YES
NO
CORR.
28
LICENSE TYPE
VAL.
O
C
CDL RESTRICTIONS
29
M
GROUP DESIGNATION
GDL 1 GDL 2 GDL 3
SAVE CASE NUMBER
PID
A
ENDORSEMENTS
B
C
CY F H N P R S T SEAS.
SOCIAL SECURITY DOCUMENT PRESENTED
30
LEGAL PRESENCE DOCUMENT PRESENTED
U.S. BIRTH CERTIFICATE
(original or certified copy)
U.S. PASSPORT OR PASSPORT CARD
(valid, unexpired)
ARRIVAL AND DEPARTURE FORM
(I-94)
U.S. VISA
(immigrant or non-immigrant)
PERMANENT RESIDENT CARD (I-551)
(valid, unexpired)
EMPLOYMENT AUTHORIZATION CARD
(EAD)
CERTIFICATE OF CITIZENSHIP
(N-560, N-561)
CERTIFICATE OF NATURALIZATION
(N-550, N-570, N-578)
CONSULAR REPORT OF BIRTH ABROAD
(FS-240, DS-1350, FS-545)
STATE
COUNTY
FILE #
COUNTRY
EXP. DATE
FILE #
ISSUE DATE
EXP. DATE
FILE #
TYPE (F-1, J-1 etc.)
EXP. DATE
FILE #
ISSUE DATE
EXP. DATE
FILE #
ISSUE DATE
EXP. DATE
FILE #
ISSUE DATE
FILE #
ISSUE DATE
FILE #
ISSUE DATE
FILE #
U.S./CANADIAN DRIVER LICENSE or PID
(valid or expired less than 1 year)
FOREIGN PASSPORT
(valid or expired less than 1 year)
U.S. MILITARY ID CARD (DD-2, DD1173, CAC card)
(valid or expired less than 1 year)
U.S. LEGAL DOCUMENTS
(marriage, divorce, adoption, legal name change)
PHOTO ID CARD
(issued by federal or Michigan or tribal government agency)
U.S. SCHOOL RECORDS
(photo, diploma, transcript, yearbooks)
MDOC PRISONER ID CARD
(requires verification)
STATE
DL/PID #
FILE #
COUNTRY
EXP. DATE
FILE #
ISSUE DATE
EXP. DATE
FILE #
STATE
TYPE
FILE #
ISSUE DATE
EXP. DATE
FILE #
ID TYPE
SCHOOL
CITY, STATE, TELEPHONE #
OTHER
TYPE
IDENTITY DOCUMENT PRESENTED
FILE #
FILE #
RESIDENCY DOCUMENTS PRESENTED (at least two documents required)
RESIDENCY DOCUMENTS
TYPE
TYPE
EMPLOYEE SIGNATURE
MANAGER OR DESIGNEE SIGNATURE
X
X
ADDITIONAL
INFORMATION
Refer App? (Circle one)
BRANCH NUMBER
C
E
R
O
F
CDL
ENFORCE
RESEARCH
OTHER
FOREIGN ADDRESS
Request for exception?
DOCUMENTS IN POSSESSION OF?
Applicant
Mailed In-House
TRANSACTION #S, INCLUDING VOIDS
Branch
COMMENTS – BE SPECIFIC (Use additional pages if necessary) – If referring application or adding comments, print name, sign, and date at bottom.
DE-36 (10/12)
Authority granted under Public Act 300 of 1949, as amended.
YES
NO
WRITTEN/ORAL TEST RESULTS
Enter Date and Pass or Fail Test Score
Enter Test # for Chauffeur, Moped, Motorcycle,
and Recreational Double tests.
Operator
_____/_____/_____
P______ F______
_____/_____/_____
P______ F______
Audio Test
_____/_____/_____
P______ F______
_____/_____/_____
P______ F______
Road Sign Test
_____/_____/_____
P______ F______
_____/_____/_____
P______ F______
Moped
#______
_____/_____/_____
P____ F____
#______
_____/_____/_____
P____ F____
Motorcycle
#______
_____/_____/_____
P____ F____
#______
_____/_____/_____
P____ F____
Recreational Double
#______
_____/_____/_____
P____ F____
#______
_____/_____/_____
P____ F____
Chauffeur
#______
_____/_____/_____
P____ F____
#______
_____/_____/_____
P____ F____
Minor Restricted License
Segment 1 School # ______ Issued ___/___/____
DA Letter dated
____/____/____
CDL WRITTEN/ORAL TEST RESULTS
General Knowledge
____/____/____
P______ F______
Air Brakes
____/____/____
____/____/____
P______ F______
____/____/____
P______ F______
Audio Test
Audio Test
____/____/____
P______ F______
____/____/____
P______ F______
____/____/____
P______ F______
____/____/____
P______ F______
Combination Vehicle
Passenger
____/____/____
P______ F______
____/____/____
P______ F______
____/____/____
P______ F______
____/____/____
P______ F______
Audio Test
Audio Test
____/____/____
P______ F______
____/____/____
P______ F______
____/____/____
P______ F______
____/____/____
P______ F______
Double Trailers
School Bus
____/____/____
P______ F______
____/____/____
P______ F______
____/____/____
P______ F______
____/____/____
P______ F______
Audio Test
Audio Test
____/____/____
P______ F______
____/____/____
P______ F______
____/____/____
P______ F______
____/____/____
P______ F______
Tanker
____/____/____
P______ F______
____/____/____
P______ F______
Audio Test
____/____/____
P______ F______
____/____/____
P______ F______
Hazardous Materials (No Oral Test or Foreign Language Test Allowed)
____/____/____
P_____ F_____
____/____/____
P_____ F_____
____/____/____
P_____ F_____
____/____/____
P_____ F_____
If necessary, attach an additional DE-36 to record more test scores.
DE-36 (10/12)
P______ F______
Authority granted under Public Act 300 of 1949, as amended.