Learner s Permit Checklist

Learner’s Permit Checklist

You will need the forms below when you apply for the Learner's Permit or you

will

be

turned away. Please pay close attention to the

New Texas Rule

.

•

Important

- Do not try to apply for your Learner’s Permit until you have had your

Texas packet for at least 3 days.

1.

You must have turned in your DL-92 form and received the packet back from the

state.

2.

Verification of Enrollment Form -

Must have received this within the last 30 days. This

comes from your public or private school. Homeschoolers will have parent sign.

3. DL-90A -

This is a parent affidavit verifying completion of first 6 hours.

4.

DL-14A - Application for Driver License -

You can fill this out now, or wait until you get

to the DPS. Do not sign this, the DPS office will verify your signature.

5.

Virtual Drive Learner's Permit Progress Report –

No more than 2 hours per day.

6.

Birth Certificate (Original)

7.

Social Security Card

8.

Proof of Residency -

The parent must show 2 forms of proof of residency.

9.

DE-964E Form –

If you have re

ceived your TX Packet

after September 30, 2012 you

will be required to present a

DE-964E

form.

10. Virtual Drive Learner’s Permit

_{Proof of Enrollment}

.

Available upon completion of

Module 1.

Found at the bottom of Module 1.

New Texas Rule

All Parent Taught students who register

_ed

_{with the state}

after September 30, 2012 must present a

DE-964E Certificate of Completion along with the Virtual Drive Learner’s Permit Certificate of

Completion to be eligible to take the Learner’s Permit test at the DPS office.

DE-964E Form (#9) –

Your DE-964E Form w

ill be PDLOHG upon completion of Module 1 Quiz

and submittal of the Request for DE-964E form. Found at the bottom of Module 1.

Many of these forms are attached to this document.

If you have any questions about these forms, please contact our office at 806-352-9558 or

806-418-2474.

If you need to find the closest DPS office to your home, just click on (or go to) this link and then

enter the appropriate information.

REQUIRED INFORMATION FROM ALL APPLICANTS

YES NO

1. Do you wish to donate $1.00 to the Blindness Education Screening and Treatment Program?

2. Do you wish to donate $1.00 to the Glenda Dawson Donate Life – Texas Registry?

3. Would you like to register as an organ donor?

4. Do you have a health condition that may impede communication with a peace officer? If yes, please list

(must complete form DL-101) 5. Would you like to complete a voter registration application form today? You must be eligible.

(¿Le gustaria llenar la forma de registro de votante hoy? Tiene que ser elegible.)

6. Are you a veteran and were you honorably discharged? If yes, what branch of service?

7. Do you want a veteran designator on your driver license? (proof of honorable discharge required)

8. Have you ever had a Texas identification card? Number When?

9. Have you ever had a driver license or instruction permit in Texas? Number When?

10. Have you ever had a license or instruction permit in any other state? List state(s)

Number(s) When?

REQUIRED INFORMATION FROM DRIVER LICENSE APPLICANTS

YES NO DRIVING HISTORY INFORMATION

11. Are you enrolled in or have you completed an approved driver education course?

12. Is your driver license or driver privilege CURRENTLYor EVER beensuspended, revoked, canceled, denied or disqualified in ANYstate?

Where? When? Why?

VEHICLE REGISTRATION AND INSURANCE INFORMATION

13. Do you own a motor vehicle which is required to be registered (Texas Transportation Code Section 502.002)?

14. Do you own a motor vehicle which is required to have liability insurance OR other proof of financial responsibility in compliance with the Motor Vehicle Safety Responsibility Act (Texas Transportation Code Section 601.051)?

APPLICATION CONTINUED ON BACK

FOR DEPARTMENT USE ONLY

DOCUMENT PRESENTED:  DOCUMENT NUMBER:  ISSUING AGENCY: 

DOCUMENT PRESENTED:  DOCUMENT NUMBER:  ISSUING AGENCY: 

DOCUMENT PRESENTED:  DOCUMENT NUMBER:  ISSUING AGENCY: 

DOCUMENT PRESENTED:  DOCUMENT NUMBER:  ISSUING AGENCY: 

DOCUMENT PRESENTED:  DOCUMENT NUMBER:  ISSUING AGENCY: 

APPLICATION for: DRIVER LICENSE   COMMERCIAL DRIVER LICENSE (CDL)   LEARNER LICENSE   IDENTIFICATION CARD   NON-RESIDENT COMMERCIAL DRIVER LICENSE   APPLICANT INFORMATION LAST NAME: FIRST NAME: MIDDLE NAME: SUFFIX: MAIDEN NAME: DATE OF BIRTH: — — (MM-DD-YYYY)

SOCIAL SECURITY NUMBER:

— —

SEX: MALE FEMALE RACE: EYE COLOR: HAIR COLOR:

HEIGHT: ft. in. WEIGHT: lbs.

UNITED STATES CITIZEN: yes no

PLACE OF BIRTH: CITY: COUNTY: STATE: COUNTRY:

FATHER’S LAST NAME: MOTHER’S MAIDEN NAME:

CONTACT INFORMATION

HOME PHONE: OTHER PHONE: EMAIL:

ADDRESS INFORMATION

RESIDENCE ADDRESS: (in line below)

CITY: COUNTY:

STATE: ZIP CODE:

COUNTRY:

MAILING ADDRESS

CITY: STATE:

ZIP CODE: COUNTRY:

FOR DEPARTMENT USE ONLY

RESTRICTIONS/ENDORSEMENTS

ASSIGNED # 

DL-14A (Rev. 11/11)

APPLICATION FOR TEXAS DRIVER LICENSE

OR IDENTIFICATION CARD

NOTICE:  All information on this application, except the signature, must be TYPEWRITTEN or PRINTED in BLACK INK. The signature shall be WRITTEN in BLACK INK. ONCE THIS APPLICATION FORM AND FEE HAVE BEEN SUBMITTED,

NO REFUNDS WILL BE MADE. Applications held only 90 days.

(Circle Class Desired) CLASS A B C M

DRIVER LICENSE APPLICANTS

The answers to questions 1 through 7 below are for the confidential use of the Department

YES NO MEDICAL HISTORY QUESTIONS

1. Do you currently have or have you ever been diagnosed with or treated for any medical condition that may affect your ability to safely operate a motor vehicle?

EXAMPLES, including but not limited to:Diagnosis or treatment for heart trouble, stroke, hemorrhage or clots, high blood pressure, emphysema (within past two years) • progressive eye disorder or injury (i.e., glaucoma, macular degeneration, etc.) • loss of normal use of hand, arm, foot or leg • blackouts, seizures, loss of consciousness or body control (within the past two years) • difficulty turning head from side to side • loss of muscular control • stiff joints or neck • inadequate hand/eye coordination • medical condition that affects your judgment • dizziness or balance problems • missing limbs

Please explain and identify medical condition:

2. Within the past two years, have you been diagnosed with, been hospitalized for or are you now receiving treatment for a psychiatric disorder?

3. Have you ever had an epileptic seizure, convulsion, loss of consciousness, or other seizure?

4. Do you have diabetes requiring treatment by insulin?

5. Do you have any alcohol or drug dependencies that may affect your ability to safely operate a motor vehicle or have you had any episodes of alcohol or drug abuse within the past two years?

6. Within the past two years have you been treated for any other serious medical conditions? Please explain:

7. Have you EVERbeen referred to the Texas Medical Advisory Board for Driver Licensing?

NOTICE:  The information on this application is required by the Texas Driver License Act, Texas Transportation Code Chapter 521. Failure to provide the information is cause for refusal to issue a driver license or identification card, and in some cases, cancellation or withdrawal of the driving privilege. False information could also lead to criminal charges with penalties of a fine up to $4,000.00 and/or jail.

D

O NOT SIGN UNTIL INSTRUCTED TO DO SO BY

N

OTARY

P

UBLIC OR

D

RIVER

L

ICENSE EMPLOYEE

.

CERTIFICATION

I  do  solemnly  swear,  affirm,  or  certify  that  I  am  the  person  named  herein  and  that  the  statements  on  this  application  are  true  and  correct. I  further  certify  my  residence  address  is  a  (check  one):  (      )  single  family  dwelling,  (      )  apartment,  (      )  motel,  (      )  temporary  shelter. I agree to immediately report to the Texas Department of Public Safety any changes in my medical condition which may affect my ability to safely operate a motor vehicle. I further understand that I am required by law to report any change of name or address to the Department of Public Safety within thirty days. 

X

Date:

SOCIAL SECURITY NUMBER COLLECTION DISCLOSURE

Disclosure of your social security account number is mandatory for driver license applicants, but voluntary for identification card applicants. This informa-tion is solicited pursuant to 42 U.S.C. 405(c)(2)(C)(i), 42 U.S.C. 666(a)(13)(A); 49 C.F.R. 383.153, Texas Family Code Secinforma-tion 231.302(c)(1) and Texas Transportation Code Sections 522.021 and 521.142. The Department will use social security account number information for identification purposes and will only release the number to the Child Support Enforcement Division of the Attorney General’s Office, the U.S. Selective Service Administration and the Texas Secretary of State for statutorily authorized purposes pursuant to Texas Transportation Code Section 521.044.

VERIFICATION

Sworn to and subscribed before me this day of ,

Notary Public in and for the State of Texas/Authorized Officer

PARENTAL AUTHORIZATION

Required for all driver license applicants under the age of 18

I  do  solemnly  swear,  affirm,  or  certify  that  I  am  the  person  named  herein,  that  the  statements  on  this  application  are  true  and  correct, that the above named applicant is my (    ) child (    ) stepchild (    ) ward, and that I have legal custody of the applicant. I authorize the Department of Public Safety to issue a Class (    ) A, (    ) B, (    ) C, or (    ) M license to said minor.

Usual Written Signature of Parent or Guardian Driver License Number Date

WAIVER OF PARENTAL AUTHORIZATION

Parental Authorization waived. Authority DL Employee #

Pursuant  to  Texas  law,  the  Texas  Department  of  Public  Safety  will  provide  every  minor  applicant  (under  age  18),  and  cosigner,  for  a  driver license  in  Texas,  educational  information  concerning  state  laws  relating  to  driving  while  intoxicated,  driving  by  a  minor  with  alcohol  in  the minor’s  system,  and  the  implied  consent  law.  The  minor  applicant  and  the  cosigner  must  acknowledge  receipt  of  that  information  prior  to issuance of any driver license or permit.

I hereby acknowledge receipt of the information concerning DWI, the Zero Tolerance Law and the Implied Consent Law.

Learner’s Permit Progress Report 1

Module 1

Student

Course Number - 107

Fill in this document as you complete each appropriate lesson in Module 1. You will need to

bring this signed form with you to the DPS office when you apply for your Learner’s

Permit. This form replaces the DL-91A form.

Driving Unit Title

Hours

Date Instructor Signature

Required Completed

Permit Requirement

6

Lesson 1 & 2

Your License to Drive

2

Right of Way

Lesson 3 & 4

Traffic Control Devices

2

1

Controlling Traffic Flow

Lesson 5 & 6

Alcohol and Other Drugs

2

Cooperating with Other Drivers

As the instructor of the minor named above, I confirm that this instruction was completed as

required by the state of Texas. Training was conducted in no fewer than three days. Training was

conducted in two-hour increments per day. Training occurred after parent taught registration was

received. Virtual Drive of Texas – Course #107 curriculum was used for training.

Instructor (Print)

Instructor DL#

Instructor (Signature)

Date

I am the (circle one)

Parent

Step-Parent

Grandparent

Step-Grandparent

Legal Guardian

Appendix C

Driver License Division

Classroom Instruction - Driver Education Affidavit

For Class C Learner License

All information on this affidavit, except the signature, must be typed or printed in black ink. The signature must be written in black ink.

I, , valid Texas driver license number , hereby certify that

(Instructor’s Legal Name) (Driver License Number)

the following information contained in this form is true and correct. I am the instructor of , whose

(Student’s Legal Name)

date of birth is , thereby meeting the age requirement meeting the age requirement to obtain a

(MM-DD-YYYY)

Class C learner license. I certify that for the above-named student, I am the:



Parent



Legal guardian



Step-parent



Step-grandparent



Foster parent



Grandparent

I acknowledge if one of the above relationships doesn’t apply, then by law, I’m not authorized to teach Parent Taught Drivers Education. I certify that I:

1.

Possessed a valid driver license for the preceding three years;

2.

Have not been convicted of Criminally Negligent Homicide;

3.

Have not been convicted of Driving While Intoxicated;

4.

Have not had my driving privileges suspended, revoked or forfeited in the past three years;

5.

Had less than six surcharge points assigned to me at the time I began instructing the above-named student; and

6.

Am not disabled because of mental illness.

I certify that I have instructed my student in the following Texas Department of Public Safety approved course of instruction:



32 hours of classroom instruction under the Block Driver Education Program



6 hours of classroom instruction under the Concurrent Driver Education Program

Title of DPS-Approved PTDE Training Course: Course Number:

I acknowledge that falsely certifying the information contained in this affidavit will subject me to criminal penalties under Texas Transportation Code 521.454.

(Signature) (Date)

Sworn to and subscribed before me this day of , 20 .

(Notary Public in and for the State of Texas/Authorized Officer)

NOTE: One affidavit is required for each instructor who taught a student in each phase of the course. If there is more than one instructor, this form may be photocopied for use by the other instructor(s). All instructors must accompany the student when apply for a learner license. This affidavit must be signed either before a Driver License employee at the driver license office or before a Notary Public before coming to the driver license office. The document(s) must be presented when the student applies for a learner license. Definition of a qualified instructor can be found in the PTDE Information Packet.

FOR DPS USE ONLY

Texas Driver Education Certificate (DE-964) #: DL-90A (Rev. 02/12)

Texas Residency Requirement for Driver Licenses and ID Cards

To verify Texas residency, an individual must present two documents from the drop down menu below. Both documents must contain the individual’s name and residential address. One of the documents must verify that the individual has lived in Texas for at least 30 days. This 30-day requirement is waived for individuals who are surrendering a valid, unexpired driver license from another state.

Individuals who are unable to provide two acceptable documents may be eligible to complete a Texas Residency Affidavit.

Residency Documents

Any of the following documents will be accepted to verify an individual’s Texas residency. The two documents provided must be issued by different companies or agencies. For example, an individual may not use a water bill and an electricity bill from the same company.

•

Current deed, mortgage, monthly mortgage statement, mortgage payment booklet or a residential

rental/lease agreement

•

Valid, unexpired Texas voter registration card

•

Texas motor vehicle registration or title

•

Texas boat registration or title

•

Texas concealed handgun license

•

Utility statement (including electric, water, natural gas, satellite TV, cable TV or noncellular phone bill)

dated within 90 days of the date of application

•

Selective Service card

•

Medical or health card

•

Current homeowner’s or renter’s insurance policy or homeowner’s or renter’s insurance statement

•

Current automobile insurance policy or an automobile insurance statement

•

Texas high school, college or university report card or transcript for the current school year

•

W-2 or 1099 tax form from the current tax year

•

Mail from financial institutions; including checking, savings, investment account and credit card

statements dated within 90 days of the date of application

•

Mail from a federal, state, county or city government agency dated within 90 days of the date of

application

•

Current automobile payment booklet

•

Pre-printed paycheck or payment stub dated within 90 days of the date of application

•

Current documents issued by the U.S. military indicating residence address

•

Document from the Texas Department of Criminal Justice indicating the applicant's recent release or

parole

•

Current Form DS2019, I-20 or a document issued by U.S. Citizenship and Immigration Services

Residency Requirement Waived

The residency requirement will be waived for individuals who are authorized to use an alternative address under the following circumstances:

1. Individuals subject to the Address Confidentiality Program (ACP) administered by the Attorney General

of Texas

2. Judges or spouses of judges

3. Individuals currently incarcerated in a Texas Department of Criminal Justice facility