REQUEST FOR A CONNECTICUT DRIVER'S: LICENSEIDENTIFICATION CARD BY MAIL 5-350 Rev. 8-19, STATE OF Connecticut DEPARTMENT OF MOTOR VEHICLES. (SEE INSTRUCTIONS ON BACK) DMV VALIDATION AREA ag ‘WANE OF APPLICANT ON ORWERS LICENSE [ast Fret Hale ia ‘DRIVERS UGENSE ORID GARD NUMBER [Faro Dave OF aT “STREET ADDRES WERE LICENSE Yo BE MAILED eye CoLoR ‘GENER eo aa aE coun “ZPPOSTAL CODE [CLASS ire) FROORSENENTS Whsaw) [RESTRICTIONS inn) ‘SECTION A. [LD ourorstate oTHER (expiai: [5] ouror-country [_] INCARCERATEDINMATE NUMBER: mura a (Complete Section E on back of form) [] buPLicare License (590.00) [D) DUPLICATE NON-ORIVER IDENTIFICATION CARD ($30.00) [~] RENEWAL OF DRIVER LICENSE (572066 ou renew 5200 for2 [DUPLICATE LEARNER PERMIT ($19.0) DRIVER LICENSE RENEWALS ONLY: IF YOU ARE RENEWING YOUR DRIVERS LICENSE THIS FORM MUST BE RECEIVED BY ‘THE DMV PRIOR TO YOUR EXPIRATION DATE. {AN ADDITIONAL LATE FEE OF $25 WILL APPLY IF YOUR RENEWAL AND PAYMENT. 1] RENEWAL OF NON-ORIVER ID (522 50) ( tosr year renenst A 2 yer renewals ony avadole or operators 03 yeas or ae). OO stom J vestroveo RECEIVED BY DMV AFTER YOUR EXPIRATION DATE. ‘CONNECTICUT RESIDENT ADDRESS her Sex Cy Town, Stat, 2 Cody) WLITARY: Cone ase re natn ‘CORRECTICUT WAILNG ADDRESS (Fair Far Conese maton ae) Cvs [no from TS GORY GAUGE BE USED To CHANGE YOUR ADDRESS PERMANENTLY = TOU MUST ceLeve A NOM/OUAL CHANGE Gr ADDRESS (6-6 YO CHANGE 100 YOU WANT TOBE INTHE ORGANTISSUE DONOR REGISTRY? [ves [-] no. EVES. YOU ARE AGREEING TO BE A DONOR AND ‘THE DESIGNATION WILL BE ON YOUR LICENSE ‘SECTION B - CERTIFICATION FOR DRIVER'S LICENSES AND IDENTIFICATION CARDS {Re maton prowa ene Conmestrar fo venice on ft bere yr, rar. nde pay of Ba.WUioatneComostoa Cone States lundertund hat mace rsa atom beimve Eo We sth ne mo mes he Cansei ole srearr arm under sty ose satrrs, at ny rs Kane ang Plage ent uence ete ot x SECTION C- FEES ‘SECTION D - VOTER REGISTRATION APPLICATION Circle applicable fees and determine correct amount 70 APPLY TO REGISTER TO VOTE YOU MUST BE: A Unied Sse czar. a TRANSACTION TYPE FEE Grtomvnars use apngtorpasr ioscan ne Dupe Lx tafe antenna | gag Avo youa cizenofheUnied Sate of mares?) YES] NO et itt oer tageonorotre sein dy?) ves no Dal rie rin Carter paomel ero | en you cca "NO" pene ea a | sxemorteomsietommteesy Od Narain | Dupleste LsamerPermt |__| $1900 __| "5. you wish te enrallin « potical party? | Renewalotnonoweri | aso (ves NAME oF PARTY: [) DEWoceATIC [REPUBLICAN $200 a 0 omer: sao No 100 Nor WrsH TO ENROLL WA PARTY AT TH TME AND eee \WGLbE REGISTERED Ne UNAFFILIATED LATE FEE forte ena of verte (Ate fo ite Note: Dchring party enables you to vt in te pays pinary con, whichis sphcjen acecaore rt relte payer) RECENED by | $2500 i carer fo pry mooors You ay tt chooso 1 cach anys oor fom si ate fe nto ae) Se ae ——————— LEAVING Tag SECTION BLANK WiLL AUTOMATICALLY RESULTIN 1 PavMent ENCLOSED (chock or money ord) (1) creorr caRo PAYMENT (P2ase cal 860)263.5401 1 business day at ‘emalngaxing the frm to prone erect card number. Credit ear payin must be veceied poor to expiration date or heat ee wl app). VOTER DECLARATION + epear or afm under any of parury that “amos Cheer nny Pet imal east Years ol and wl be 18 years ci on a before election day ave nol been Convicted ofa daanchisng ean. oso, Lamsligtle to ragterto ete jONATURE OF APPLICANT ]Tooavs onTe | Peter reictatione witout agnataros wit tbe promoased ‘The Information ths | nave provided is tue 0 te best of my kpowlesoe under Donat of popu fave povaod fase Ivomaten, may be subjects fe oF Lmmprscemont or bot unde edo sata ws By signing tis Jom, | agro to alow the signature fom my lcanso cata te Bo napa ae tne crate ontare voto’ rootstration rocaINSTRUCTIONS: NOTE: Qutof State/Country Applicants: You MUST provide an out of state/country address, if you do not provide an out of. slateicountry address your application eannet be processed by mail and you must appear at your local branch office. ‘Your Connecticut licenselidentification will be sent to the out of state/country address provided via regular mail 1. Only legal residents of Connecticut with a VALID CT licenselidentiication card who meet the following criteria may Use this application: a) must be temporarily located out of statelout of country b) currently incarcerated ¢) currently suffering from an incapacitating medical condition, which does not allow you to appear in person for your duplicate/renewal. (See number 5 for additional requirements) 2. Complete section A entirely. Type or print clearly. Sign the certification in section B. 3. Complete Section D if you want to apply to register to vote in CT. To register, you must be a U.S. citizen and at least 48 years old before the next election. You are not a voter until your application is approved by the registrar of voters in your CT town of residence. If you do not receive an acceptance or rejection within three weeks, contact the registrar of voters, 4, Military: If recently honorably discharged or an active member of the armed services of the United States, Section E (below) must be completed if requesting a no fee renewal. A fee exemption is not given for duplicate licenses or Identification cards, 5. Medical Condition: If request is due to a incapacitating medical condition this application must be submitted with the Request fo renew or obtain duplicate by mail due to medical conditions (Cl-1) form 6. Send completed application through either postal mail, e-mail or fax (email or fax will reduce wait time). MAIL ‘Send the completed application and payment (fees are listed in section C) of check or money order drawn on United States bank (dollar currency) and mailto: Department of Motor Vehicles 60 State Street Wethersfield, CT 06109 Attn: Central Issuance Operations Unit E-MAIL OR FAX E-mail completed form(s) to DMV. CIU@et gov or fax to 860-263-5591. After one business day contact the Cental Issuance Operations Unit at 860 263-5401 (Monday-Friday 8:30 a.m, to 3.00 p.m.) to make a credit card payment (MASTERCARD, VISA OR DISCOVER ONLY). NOTE - LICENSE RENEWALS: Payments must be received prior to or the day of expiration or $25.00 late fee will be charged. ‘The following transactions cannot process through the mail: Renewal of commercial driver license (CDL), public service license, name change, or drive-only permitlicense. Per the REAL ID act you are allowed only one renewal through the mail before a new photo is required ACTIVE MILITARY PERSONNEL ONLY SECTION E ‘Connecticut General Statutes, Section 14-50(e), The Commissioner of Motor Vehicies shall waive the operators leanse fee and examination fee in the case ‘of any person in the active service ofthe armed forces of the United States who was a legal resident of Connecticut at the time of his induction; and for one licensing period to any person honorably separated from service who apples therefore within two years folowing the date of separation and was a legal resident of Connecticut atthe time of his induction, IAMENTTTLED TOA WAIVER gy, [] Pvenctve seven Aimed Free DATE OFINDUCTION __—DATEOF SEPARATION BECAUSE OF (Check One) 1 (repeal aretns eprom at Sat y of seprton papers 00214) | certty that was a legal resident of the state of Connecticut at he time of my induction and that ll SIONATUREOF APPLICANT Information provided inthis application ie correct. x "certiy under penalty of alse statement in accordance with provision of Section 14-110 and 632-157) _SIONATURE OF COMMISSIONED OFFICER I\GHARGE (Ae) ‘General Statutes thatthe above named applicant isin the active service ofthe US. understand that i make a statement which do not believe tobe tue, with the 1d the Commissioner, Iwill be subject to prosecution under the above referenced lans. 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