Form R-229 Application for a Non-commercial Learner Permit and/Or Driver License - Connecticut

Form R-229 or the "Application For A Non-commercial Learner Permit And/or Driver License" is a form issued by the Connecticut Department of Motor Vehicles.

Download a PDF version of the Form R-229 down below or find it on the Connecticut Department of Motor Vehicles Forms website.

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DMV USE
OUT OF STATE
CHANGE ENDORSEMENT/
NEW
RETEST
EXCHANGE
ONLY
TRANSFER
RESTRICTION
APPLICATION FOR A NON-COMMERCIAL
STATE OF CONNECTICUT
LEARNER PERMIT AND/OR DRIVER LICENSE
DEPARTMENT OF MOTOR VEHICLES
R-229 REV. 7-2013
On The Web At ct.gov/dmv
INSTRUCTIONS: Complete 1-16, then present
1.
Required Identification Documents & Proof of Connecticut
Residency: see "Acceptable Forms of ID" at ct.gov/dmv
2.
16 and 17 year olds: Certificate of Parental Consent Form 2D
LEARNER PERMIT NUMBER
DATE OF ISSUE
(if not accompanied by authorized individual)
3.
Applicable Fees
APPLICANT'S NAME (Last, First, Middle, Suffix)
1.
2. SEX
3. DATE OF BIRTH
4. HEIGHT
5. COLOR OF EYES
M
F
ft.
in.
6.
MAILING ADDRESS (No., Street, City or Town, State, Zip Code)
7. RESIDENCE ADDRESS (If different)
DAYTIME PHONE NO.
8.
US CITIZEN?
If "NO", list ALIEN REGISTRATION NO.
9.
CONNECTICUT
10.
DO YOU WANT TO BE IN THE ORGAN/TISSUE DONOR
RESIDENT?
REGISTRY?
If yes, you are agreeing to be a donor
and the designation will be on your
Yes
No
Yes
No
(
)
Yes
No
license.
11. SOCIAL SECURITY NUMBER
12. LIST ANY OTHER NAMES EVER USED (Alias, Maiden, etc)
QUESTIONS
YES ( ) NO ( )
FAILED
LOCATION/DATE
13.
Have you previously failed a driver's license
KNOWLEDGE
VISION
ROAD SKILLS
examination in Connecticut?
IF YES, IN WHAT YEAR(S)?
CONNECTICUT PERMIT, LICENSE OR ID NO. (9 digits)
Do you now, or have you ever held a Connecticut Learner Permit,
14.
License or Non-Driver Identification card?
STATE, DRIVER LICENSE OR ID. NO.
NO. OF YEARS
15.
Do you now hold or have you ever held an operator's license or
identification card from another state?
IN WHAT STATE(S)?
16.
Is your privilege to operate a motor vehicle suspended or subject to
suspension in Connecticut or in any other state?
Section 14-36l of the Connecticut General Statutes requires the Commissioner to transmit my
information to the Selective Service System. By signing and submitting this application, I consent
I hereby certify that I do not
SELECTIVE
MEDICAL
to be registered with the Selective Service System, provided I am at least age 16 but under age
have any health or vision
SERVICE
26 and meet the criteria for registration in accordance with the Military Selective Service Act. If I
problems or conditions that
CERTIFICATION
CONSENT
am under age 18, I understand that my information will be transmitted to Selective Service but I
prevent me from driving safely.
will not be registered until I reach age 18.
The information provided to the Commissioner of Motor Vehicles herein is
SIGNATURE OF APPLICANT
DATE SIGNED
subscribed by me, under penalty of false statement, in accordance with
CERTIFICATION
the provisions of Section 14-110 and 53a-157b of the Connecticut General
Statutes. I understand that if I make a statement which I do not believe to
BY APPLICANT
be true, with the intent to mislead the Commissioner, I will be subject to
X
prosecution under the above-cited laws.
DO NOT WRITE BELOW THIS LINE - OFFICE USE ONLY
PROOF OF
TYPE OF ACCEPTABLE I.D. SHOWN
EXAMINER INITIAL
STAMP NO.
I.D. SCANNED FIRST VISIT
IDENTIFICATION
If different than entered in name section above (# 1)
FULL LEGAL
NAME
PARENTAL
RELATIONSHIP TO MINOR
SIGNED (Authorized Consenter)
CONSENTER'S LIC. NO. OR OTHER I.D.
I hereby request that a learner's permit
CONSENT
and/or license be issued to the minor
X
filing this application.
AGE 16 OR 17 ONLY
VISION
PUNCH NO. AND PUNCH
VISUAL AID USED
RESULTS
AGENTS INITIALS
SCREENING
NONE
GLASSES/CONTACTS
PASSED
FAILED
RESULTS
TEST RESULTS
IDENTIFICATION DOCUMENTS
APPLICANT INITIALS
KNOWLEDGE
RETURNED
COMPUTER
WRITTEN
ORAL
TEST
WAIVED
PASSED
FAILED
ISSUE PERMIT WITH CORRECTIVE LENSES
PERMIT
ISSUE LEARNER PERMIT
ISSUE MOTORCYCLE PERMIT
(B-RESTRICTION)
I hereby certify that I have examined the applicant's identity
SIGNED (Agent)
PUNCH NO. AND PUNCH
DATE SIGNED
AGENT
documents and the test results stated herein are true and
X
CERTIFICATION
correct.
SCHOOL NAME
COMMERCIAL SCHOOL LICENSE NO.
DRIVER EDUCATION CERTIFICATE NO.
CLASSROOM
INSTRUCTION
DRIVER
TRAINING
SCHOOL NAME (If same as above print "same") COMMERCIAL SCHOOL LICENSE NO.
DRIVER EDUCATION CERTIFICATE NO.
PRACTICE
DRIVING
I hereby subscribe and certify under penalty of false statement, in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes that I
understand that if I make a statement, which I do not believe to be true, with the intent to mislead the Commissioner I will be subject to prosecution under the above-cited laws, that,
HOME
I am qualified under Section 14-36, of the Connecticut General Statutes, over 20 years of age, have no suspensions within the previous 4 years and the Applicant has received the
required training, including the equivalent of 22 hours classroom training; 40 hours on-the-road instruction; the 8 hours Safe Driver course, including a 2 hour Parent Training, as
TRAINING/
supported by a parent log and/or driving school certificate.
COMMERCIAL
SIGNATURE OF INSTRUCTOR (Home Training/Commercial)
OPERATOR LICENSE NUMBER OR
1
2
3
SCHOOL LICENSE NUMBER
TRAINING
Home Training
Comm/Sec and Home
Comm/Sec Only
22 hr class equiv
30 hrs class/minimum
30 hrs class
CERTIFICATION
40 hr on-the-road
8 hr safe driving plus home
40 hrs on-the-road
8 hr safe driving
training 40 hrs on-the-road
X
NO FEE
SPECIAL EQUIPMENT
U.S.
WAIVED
PASSED
FAILED
ROAD TEST
SERVICE
AND LICENSE
NON-COMMERCIAL CLASS
ENDORSEMENT RESTRICTIONS (Circle All Applicable)
INFORMATION
D
M
Q
B
C
D
E
F
G
R
U
I hereby certify that I have verified the applicant's
SIGNED (Agent)
PUNCH NO. AND PUNCH
DATE SIGNED
AGENT
identity and the test results stated herein are true
CERTIFICATION
and correct.
DISTRIBUTION:
White - Branch Office
Canary - Agent
Pink - Examiner
DMV USE
OUT OF STATE
CHANGE ENDORSEMENT/
NEW
RETEST
EXCHANGE
ONLY
TRANSFER
RESTRICTION
APPLICATION FOR A NON-COMMERCIAL
STATE OF CONNECTICUT
LEARNER PERMIT AND/OR DRIVER LICENSE
DEPARTMENT OF MOTOR VEHICLES
R-229 REV. 7-2013
On The Web At ct.gov/dmv
INSTRUCTIONS: Complete 1-16, then present
1.
Required Identification Documents & Proof of Connecticut
Residency: see "Acceptable Forms of ID" at ct.gov/dmv
2.
16 and 17 year olds: Certificate of Parental Consent Form 2D
LEARNER PERMIT NUMBER
DATE OF ISSUE
(if not accompanied by authorized individual)
3.
Applicable Fees
APPLICANT'S NAME (Last, First, Middle, Suffix)
1.
2. SEX
3. DATE OF BIRTH
4. HEIGHT
5. COLOR OF EYES
M
F
ft.
in.
6.
MAILING ADDRESS (No., Street, City or Town, State, Zip Code)
7. RESIDENCE ADDRESS (If different)
DAYTIME PHONE NO.
8.
US CITIZEN?
If "NO", list ALIEN REGISTRATION NO.
9.
CONNECTICUT
10.
DO YOU WANT TO BE IN THE ORGAN/TISSUE DONOR
RESIDENT?
REGISTRY?
If yes, you are agreeing to be a donor
and the designation will be on your
Yes
No
Yes
No
(
)
Yes
No
license.
11. SOCIAL SECURITY NUMBER
12. LIST ANY OTHER NAMES EVER USED (Alias, Maiden, etc)
QUESTIONS
YES ( ) NO ( )
FAILED
LOCATION/DATE
13.
Have you previously failed a driver's license
KNOWLEDGE
VISION
ROAD SKILLS
examination in Connecticut?
IF YES, IN WHAT YEAR(S)?
CONNECTICUT PERMIT, LICENSE OR ID NO. (9 digits)
Do you now, or have you ever held a Connecticut Learner Permit,
14.
License or Non-Driver Identification card?
STATE, DRIVER LICENSE OR ID. NO.
NO. OF YEARS
15.
Do you now hold or have you ever held an operator's license or
identification card from another state?
IN WHAT STATE(S)?
16.
Is your privilege to operate a motor vehicle suspended or subject to
suspension in Connecticut or in any other state?
Section 14-36l of the Connecticut General Statutes requires the Commissioner to transmit my
information to the Selective Service System. By signing and submitting this application, I consent
I hereby certify that I do not
SELECTIVE
MEDICAL
to be registered with the Selective Service System, provided I am at least age 16 but under age
have any health or vision
SERVICE
26 and meet the criteria for registration in accordance with the Military Selective Service Act. If I
problems or conditions that
CERTIFICATION
CONSENT
am under age 18, I understand that my information will be transmitted to Selective Service but I
prevent me from driving safely.
will not be registered until I reach age 18.
The information provided to the Commissioner of Motor Vehicles herein is
SIGNATURE OF APPLICANT
DATE SIGNED
subscribed by me, under penalty of false statement, in accordance with
CERTIFICATION
the provisions of Section 14-110 and 53a-157b of the Connecticut General
Statutes. I understand that if I make a statement which I do not believe to
BY APPLICANT
be true, with the intent to mislead the Commissioner, I will be subject to
X
prosecution under the above-cited laws.
DO NOT WRITE BELOW THIS LINE - OFFICE USE ONLY
PROOF OF
TYPE OF ACCEPTABLE I.D. SHOWN
EXAMINER INITIAL
STAMP NO.
I.D. SCANNED FIRST VISIT
IDENTIFICATION
If different than entered in name section above (# 1)
FULL LEGAL
NAME
PARENTAL
RELATIONSHIP TO MINOR
SIGNED (Authorized Consenter)
CONSENTER'S LIC. NO. OR OTHER I.D.
I hereby request that a learner's permit
CONSENT
and/or license be issued to the minor
X
filing this application.
AGE 16 OR 17 ONLY
VISION
PUNCH NO. AND PUNCH
VISUAL AID USED
RESULTS
AGENTS INITIALS
SCREENING
NONE
GLASSES/CONTACTS
PASSED
FAILED
RESULTS
TEST RESULTS
IDENTIFICATION DOCUMENTS
APPLICANT INITIALS
KNOWLEDGE
RETURNED
COMPUTER
WRITTEN
ORAL
TEST
WAIVED
PASSED
FAILED
ISSUE PERMIT WITH CORRECTIVE LENSES
PERMIT
ISSUE LEARNER PERMIT
ISSUE MOTORCYCLE PERMIT
(B-RESTRICTION)
I hereby certify that I have examined the applicant's identity
SIGNED (Agent)
PUNCH NO. AND PUNCH
DATE SIGNED
AGENT
documents and the test results stated herein are true and
X
CERTIFICATION
correct.
SCHOOL NAME
COMMERCIAL SCHOOL LICENSE NO.
DRIVER EDUCATION CERTIFICATE NO.
CLASSROOM
INSTRUCTION
DRIVER
TRAINING
SCHOOL NAME (If same as above print "same") COMMERCIAL SCHOOL LICENSE NO.
DRIVER EDUCATION CERTIFICATE NO.
PRACTICE
DRIVING
I hereby subscribe and certify under penalty of false statement, in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes that I
understand that if I make a statement, which I do not believe to be true, with the intent to mislead the Commissioner I will be subject to prosecution under the above-cited laws, that,
HOME
I am qualified under Section 14-36, of the Connecticut General Statutes, over 20 years of age, have no suspensions within the previous 4 years and the Applicant has received the
required training, including the equivalent of 22 hours classroom training; 40 hours on-the-road instruction; the 8 hours Safe Driver course, including a 2 hour Parent Training, as
TRAINING/
supported by a parent log and/or driving school certificate.
COMMERCIAL
SIGNATURE OF INSTRUCTOR (Home Training/Commercial)
OPERATOR LICENSE NUMBER OR
1
2
3
SCHOOL LICENSE NUMBER
TRAINING
Home Training
Comm/Sec and Home
Comm/Sec Only
22 hr class equiv
30 hrs class/minimum
30 hrs class
CERTIFICATION
40 hr on-the-road
8 hr safe driving plus home
40 hrs on-the-road
8 hr safe driving
training 40 hrs on-the-road
X
NO FEE
SPECIAL EQUIPMENT
U.S.
WAIVED
PASSED
FAILED
ROAD TEST
SERVICE
AND LICENSE
NON-COMMERCIAL CLASS
ENDORSEMENT RESTRICTIONS (Circle All Applicable)
INFORMATION
D
M
Q
B
C
D
E
F
G
R
U
I hereby certify that I have verified the applicant's
SIGNED (Agent)
PUNCH NO. AND PUNCH
DATE SIGNED
AGENT
identity and the test results stated herein are true
CERTIFICATION
and correct.
DISTRIBUTION:
White - Branch Office
Canary - Agent
Pink - Examiner
DMV USE
OUT OF STATE
CHANGE ENDORSEMENT/
NEW
RETEST
EXCHANGE
ONLY
TRANSFER
RESTRICTION
APPLICATION FOR A NON-COMMERCIAL
STATE OF CONNECTICUT
LEARNER PERMIT AND/OR DRIVER LICENSE
DEPARTMENT OF MOTOR VEHICLES
R-229 REV. 7-2013
On The Web At ct.gov/dmv
INSTRUCTIONS: Complete 1-16, then present
1.
Required Identification Documents & Proof of Connecticut
Residency: see "Acceptable Forms of ID" at ct.gov/dmv
2.
16 and 17 year olds: Certificate of Parental Consent Form 2D
LEARNER PERMIT NUMBER
DATE OF ISSUE
(if not accompanied by authorized individual)
3.
Applicable Fees
APPLICANT'S NAME (Last, First, Middle, Suffix)
1.
2. SEX
3. DATE OF BIRTH
4. HEIGHT
5. COLOR OF EYES
M
F
ft.
in.
6.
MAILING ADDRESS (No., Street, City or Town, State, Zip Code)
7. RESIDENCE ADDRESS (If different)
DAYTIME PHONE NO.
8.
US CITIZEN?
If "NO", list ALIEN REGISTRATION NO.
9.
CONNECTICUT
10.
DO YOU WANT TO BE IN THE ORGAN/TISSUE DONOR
RESIDENT?
REGISTRY?
If yes, you are agreeing to be a donor
and the designation will be on your
Yes
No
Yes
No
(
)
Yes
No
license.
12. LIST ANY OTHER NAMES EVER USED (Alias, Maiden, etc)
QUESTIONS
YES ( ) NO ( )
FAILED
LOCATION/DATE
13.
Have you previously failed a driver's license
KNOWLEDGE
VISION
ROAD SKILLS
examination in Connecticut?
IF YES, IN WHAT YEAR(S)?
CONNECTICUT PERMIT, LICENSE OR ID NO. (9 digits)
Do you now, or have you ever held a Connecticut Learner Permit,
14.
License or Non-Driver Identification card?
STATE, DRIVER LICENSE OR ID. NO.
NO. OF YEARS
15.
Do you now hold or have you ever held an operator's license or
identification card from another state?
IN WHAT STATE(S)?
16.
Is your privilege to operate a motor vehicle suspended or subject to
suspension in Connecticut or in any other state?
Section 14-36l of the Connecticut General Statutes requires the Commissioner to transmit my
information to the Selective Service System. By signing and submitting this application, I consent
I hereby certify that I do not
SELECTIVE
MEDICAL
to be registered with the Selective Service System, provided I am at least age 16 but under age
have any health or vision
SERVICE
26 and meet the criteria for registration in accordance with the Military Selective Service Act. If I
problems or conditions that
CERTIFICATION
CONSENT
am under age 18, I understand that my information will be transmitted to Selective Service but I
prevent me from driving safely.
will not be registered until I reach age 18.
The information provided to the Commissioner of Motor Vehicles herein is
SIGNATURE OF APPLICANT
DATE SIGNED
subscribed by me, under penalty of false statement, in accordance with
CERTIFICATION
the provisions of Section 14-110 and 53a-157b of the Connecticut General
Statutes. I understand that if I make a statement which I do not believe to
BY APPLICANT
be true, with the intent to mislead the Commissioner, I will be subject to
X
prosecution under the above-cited laws.
DO NOT WRITE BELOW THIS LINE - OFFICE USE ONLY
PROOF OF
TYPE OF ACCEPTABLE I.D. SHOWN
EXAMINER INITIAL
STAMP NO.
I.D. SCANNED FIRST VISIT
IDENTIFICATION
If different than entered in name section above (# 1)
FULL LEGAL
NAME
PARENTAL
RELATIONSHIP TO MINOR
SIGNED (Authorized Consenter)
CONSENTER'S LIC. NO. OR OTHER I.D.
I hereby request that a learner's permit
CONSENT
and/or license be issued to the minor
X
filing this application.
AGE 16 OR 17 ONLY
VISION
PUNCH NO. AND PUNCH
VISUAL AID USED
RESULTS
AGENTS INITIALS
SCREENING
NONE
GLASSES/CONTACTS
PASSED
FAILED
RESULTS
TEST RESULTS
IDENTIFICATION DOCUMENTS
APPLICANT INITIALS
KNOWLEDGE
RETURNED
COMPUTER
WRITTEN
ORAL
TEST
WAIVED
PASSED
FAILED
ISSUE PERMIT WITH CORRECTIVE LENSES
PERMIT
ISSUE LEARNER PERMIT
ISSUE MOTORCYCLE PERMIT
(B-RESTRICTION)
I hereby certify that I have examined the applicant's identity
SIGNED (Agent)
PUNCH NO. AND PUNCH
DATE SIGNED
AGENT
documents and the test results stated herein are true and
X
CERTIFICATION
correct.
SCHOOL NAME
COMMERCIAL SCHOOL LICENSE NO.
DRIVER EDUCATION CERTIFICATE NO.
CLASSROOM
INSTRUCTION
DRIVER
TRAINING
SCHOOL NAME (If same as above print "same") COMMERCIAL SCHOOL LICENSE NO.
DRIVER EDUCATION CERTIFICATE NO.
PRACTICE
DRIVING
I hereby subscribe and certify under penalty of false statement, in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes that I
understand that if I make a statement, which I do not believe to be true, with the intent to mislead the Commissioner I will be subject to prosecution under the above-cited laws, that,
HOME
I am qualified under Section 14-36, of the Connecticut General Statutes, over 20 years of age, have no suspensions within the previous 4 years and the Applicant has received the
required training, including the equivalent of 22 hours classroom training; 40 hours on-the-road instruction; the 8 hours Safe Driver course, including a 2 hour Parent Training, as
TRAINING/
supported by a parent log and/or driving school certificate.
COMMERCIAL
SIGNATURE OF INSTRUCTOR (Home Training/Commercial)
OPERATOR LICENSE NUMBER OR
1
2
3
SCHOOL LICENSE NUMBER
TRAINING
Home Training
Comm/Sec and Home
Comm/Sec Only
22 hr class equiv
30 hrs class/minimum
30 hrs class
CERTIFICATION
40 hr on-the-road
8 hr safe driving plus home
40 hrs on-the-road
8 hr safe driving
training 40 hrs on-the-road
X
NO FEE
SPECIAL EQUIPMENT
U.S.
WAIVED
PASSED
FAILED
ROAD TEST
SERVICE
AND LICENSE
NON-COMMERCIAL CLASS
ENDORSEMENT RESTRICTIONS (Circle All Applicable)
INFORMATION
D
M
Q
B
C
D
E
F
G
R
U
I hereby certify that I have verified the applicant's
SIGNED (Agent)
PUNCH NO. AND PUNCH
DATE SIGNED
AGENT
identity and the test results stated herein are true
CERTIFICATION
and correct.
DISTRIBUTION:
White - Branch Office
Canary - Agent
Pink - Examiner
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