Form DMV-DS-23P "Application for a Driver's License or Identification Card" - West Virginia

What Is Form DMV-DS-23P?

This is a legal form that was released by the West Virginia Department of Transportation - a government authority operating within West Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2019;
  • The latest edition provided by the West Virginia Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DMV-DS-23P by clicking the link below or browse more documents and templates provided by the West Virginia Department of Transportation.

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Download Form DMV-DS-23P "Application for a Driver's License or Identification Card" - West Virginia

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DMV-DS-23P REVISED 04/2019
Application for a Driver’s License or Identi cation Card
West Virginia DMV
PO BOX 17010
Complete both sides of this application. All requested information is mandatory unless otherwise noted.
Charleston, WV 25317
/
/
Name
WV License #
Birth date
LAST, FIRST, AND MIDDLE
MM
DD
YYYY
Gender
Former Names
Weight
Height
LBS
FT
IN
SUPPORTING LEGAL DOCUMENTATION IS REQUIRED BY LAW
Residence Address
Eye Color
Do you wear corrective lenses?
County of Residence
(
)
-
Daytime Phone
(optional)
Mailing Address
(
)
-
REQUIRED IF DIFFERENT FROM RESIDENCE ADDRESS
Cellular Phone
(optional)
City, State, ZIP code
Email Address
(optional)
Social Security Number
YOU MUST ANSWER “YES” OR “NO” TO ALL QUESTIONS BELOW UNLESS YOU DO NOT MEET THE QUESTION’S CRITERIA.
YES
NO
Do you wish to be designated on your license as an organ donor?
By checking “yes”, you agree that the DMV may furnish your personal information to designated
Has your address changed since your last License/ID issuance?
O rg an
organ donation groups.
D on o r
If “yes”, please list previous address below:
I n d ic ato r
_____________________________________________________________________________
Do you wish to be designated on your license as diabetic?
If “yes”, a
Please remember WV Law requires you to notify DMV within 20 days after a change of address.
licensed physician must certify your condition by completing the MEDICAL ENDORSEMENT section
D i a bet ic
on side two of this application.
I n d i cato r
Are you a U.S. Citizen? If not, list your Alien Registration Number below.
Do you wish to be designated on your license as hearing impaired?
____________________________________________________________________________
If “yes”, a licensed audiologist must certify your condition by completing the MEDICAL ENDORSEMENT
Hearing
section on side two of this application.
Impaired
Have you been issued a license/ID in another jurisdiction in the last 10 years?
Indicator
If “yes”, list jurisdiction and License/ID#(s):__________________________
Veterans of the United States Military ONLY: Do you wish to have the
United States Veterans designation on your license?
If you choose to have the
Do you have a suspended/revoked license or a pending license
veterans designation, DMV is required to verify your status with your DD Form 214, WD AGO 53,
suspension/revocation in ANY jurisdiction within the previous ve years?
WD AGO 55, WD AGO 53-55, NAVPERS 553, NAVMC 78PD, NAVCG 553, Military Identi cation Card, or
a Current Military license plate registration card. (A CSR may verify status as a current military license
If “yes”, you are required to provide a letter of explanation including the date of the incident.
VETERANS
plate holder through the vehicle system if an applicant does not have their registration card on hand.)
DESIGNATION
Have you been refused a license by any jurisdiction within the previous
ve years?
Have you ever experienced seizures or loss of consciousness, emotional
If “yes”, you are required to provide a letter of explanation including the date of
or mental illness, alcohol or drug problems, or any physical condition
the incident.
that requires you to use special equipment to drive?
If “yes”, you are required
APPLICANTS THAT OWE A CHILD SUPPORT OBLIGATION ONLY: Do you
to provide a letter of explanation.
owe an obligation that is more than six months in arrears?
Are you currently registered to vote?
If “yes”, declare if you need to update or transfer your voter information:
APPLICANTS THAT OWE A CHILD SUPPORT OBLIGATION ONLY: Are you
the subject of a child support-related warrant, subpoena, or court order?
Are you registered to vote in another state?
If “yes”, which state?
LEVEL 2 GDL Applicants ONLY: Have you been convicted of a tra c
violation in the past six months?
Ages 18 and up ONLY: Do you wish to register to vote?
LEVEL 3 GDL Applicants ONLY: Have you been convicted of a tra c
Do you wish to make a contribution to the West Virginia State Police
violation in the past 12 months?
Forensic Laboratory Fund? If “yes”, specify the contribution amount: $
Do you have any visual/medical condition(s) a ecting your ability to
Do you wish to make a contribution to the West Virginia Department of
drive safely?
If “yes”, you are required to provide a letter of explanation.
Veterans Assistance? If “yes”, choose an amount:
$5
$10
Other:
You must complete BOTH sides of this application. An incomplete application will not be processed.
DMV-DS-23P REVISED 04/2019
Application for a Driver’s License or Identi cation Card
West Virginia DMV
PO BOX 17010
Complete both sides of this application. All requested information is mandatory unless otherwise noted.
Charleston, WV 25317
/
/
Name
WV License #
Birth date
LAST, FIRST, AND MIDDLE
MM
DD
YYYY
Gender
Former Names
Weight
Height
LBS
FT
IN
SUPPORTING LEGAL DOCUMENTATION IS REQUIRED BY LAW
Residence Address
Eye Color
Do you wear corrective lenses?
County of Residence
(
)
-
Daytime Phone
(optional)
Mailing Address
(
)
-
REQUIRED IF DIFFERENT FROM RESIDENCE ADDRESS
Cellular Phone
(optional)
City, State, ZIP code
Email Address
(optional)
Social Security Number
YOU MUST ANSWER “YES” OR “NO” TO ALL QUESTIONS BELOW UNLESS YOU DO NOT MEET THE QUESTION’S CRITERIA.
YES
NO
Do you wish to be designated on your license as an organ donor?
By checking “yes”, you agree that the DMV may furnish your personal information to designated
Has your address changed since your last License/ID issuance?
O rg an
organ donation groups.
D on o r
If “yes”, please list previous address below:
I n d ic ato r
_____________________________________________________________________________
Do you wish to be designated on your license as diabetic?
If “yes”, a
Please remember WV Law requires you to notify DMV within 20 days after a change of address.
licensed physician must certify your condition by completing the MEDICAL ENDORSEMENT section
D i a bet ic
on side two of this application.
I n d i cato r
Are you a U.S. Citizen? If not, list your Alien Registration Number below.
Do you wish to be designated on your license as hearing impaired?
____________________________________________________________________________
If “yes”, a licensed audiologist must certify your condition by completing the MEDICAL ENDORSEMENT
Hearing
section on side two of this application.
Impaired
Have you been issued a license/ID in another jurisdiction in the last 10 years?
Indicator
If “yes”, list jurisdiction and License/ID#(s):__________________________
Veterans of the United States Military ONLY: Do you wish to have the
United States Veterans designation on your license?
If you choose to have the
Do you have a suspended/revoked license or a pending license
veterans designation, DMV is required to verify your status with your DD Form 214, WD AGO 53,
suspension/revocation in ANY jurisdiction within the previous ve years?
WD AGO 55, WD AGO 53-55, NAVPERS 553, NAVMC 78PD, NAVCG 553, Military Identi cation Card, or
a Current Military license plate registration card. (A CSR may verify status as a current military license
If “yes”, you are required to provide a letter of explanation including the date of the incident.
VETERANS
plate holder through the vehicle system if an applicant does not have their registration card on hand.)
DESIGNATION
Have you been refused a license by any jurisdiction within the previous
ve years?
Have you ever experienced seizures or loss of consciousness, emotional
If “yes”, you are required to provide a letter of explanation including the date of
or mental illness, alcohol or drug problems, or any physical condition
the incident.
that requires you to use special equipment to drive?
If “yes”, you are required
APPLICANTS THAT OWE A CHILD SUPPORT OBLIGATION ONLY: Do you
to provide a letter of explanation.
owe an obligation that is more than six months in arrears?
Are you currently registered to vote?
If “yes”, declare if you need to update or transfer your voter information:
APPLICANTS THAT OWE A CHILD SUPPORT OBLIGATION ONLY: Are you
the subject of a child support-related warrant, subpoena, or court order?
Are you registered to vote in another state?
If “yes”, which state?
LEVEL 2 GDL Applicants ONLY: Have you been convicted of a tra c
violation in the past six months?
Ages 18 and up ONLY: Do you wish to register to vote?
LEVEL 3 GDL Applicants ONLY: Have you been convicted of a tra c
Do you wish to make a contribution to the West Virginia State Police
violation in the past 12 months?
Forensic Laboratory Fund? If “yes”, specify the contribution amount: $
Do you have any visual/medical condition(s) a ecting your ability to
Do you wish to make a contribution to the West Virginia Department of
drive safely?
If “yes”, you are required to provide a letter of explanation.
Veterans Assistance? If “yes”, choose an amount:
$5
$10
Other:
You must complete BOTH sides of this application. An incomplete application will not be processed.
TYPE OF LICENSE / ID APPLICANT WISHES TO OBTAIN
TYPE OF LICENSE / ID APPLICANT WISHES TO OBTAIN
Any valid license / ID issued by any jurisdiction must be surrendered.
Any valid license / ID issued by any jurisdiction must be surrendered.
* Only one state issued Driver’s License or ID card per person may be designated “For Federal Identi cation”. If you choose this option you will receive a temporary license or ID card for use until you permanent card arrives in
10
approximately ten (10) business days through USPS.
PHYSICIAN / AUDIOLOGIST CERTIFICATION FOR MEDICAL ENDORSEMENT
* Only one state issued Driver’s License or ID card per person may be designated “For Federal Identi cation”. If you choose this option you will receive a temporary license or ID
card for use until you permanent card arrives in approximately ten (10) business days through UPS.
I certify that the applicant named herein is
diabetic
deaf
hard of hearing.
PHYSICIAN / AUDIOLOGIST CERTIFICATION FOR MEDICAL ENDORSEMENT
SIGNATURE (Physician for diabetic or audiologist for deaf/hard of hearing)
MEDICAL LICENSE NUMBER
STATE
(
)
-
I certify that the applicant named herein is
diabetic
deaf
hard of hearing.
ADDRESS
BUSINESS PHONE NUMBER
AFFIDAVIT OF WEST VIRGINIA RESIDENCY
Homeowner Information and Certi cation
SIGNATURE (Pysician for diabetic or audiologist for deaf/hard of hearing)
MEDICAL LICENSE NUMBER
STATE
I,
hereby swear or a rm that
FULL NAME OF APPLICANT
FULL NAME OF HOMEOWNER
resides in my home at the following address:
.
ADDRESS
BUSINESS PHONE NUMBER
STREET ADDRESS
CITY
STATE
ZIP CODE
/
/
SIGNATURE OF HOMEOWNER
WV DRIVER’S LICENSE/ID NUMBER
DATE
Males age 18 - 25 only: I understand that I am required to register for the military draft and that my information will be forwarded to the Selective Service System, as required by law.
Males age 18 - 25 only: I understand that I am required to register for the military draft and that my information will be forwarded to the Selective Service System, as required by law.
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