Form for License/ID/Permit Confirmation Number: 0-068-463-904

Who are you?

Name: DOB: SSN:
WHEELER, DARREN E 05-Apr-1989 SSN Not Provided
Previous GA License/ID/Permit: Legal Status:
Yes - 051869010 U.S. Citizen
License/ID/Permit
What are you applying for?
Commercial license/permit.
Have you ever had a Georgia, Out-of-State or Foreign Driver's License, Identification Card or Permit?
No

Driving Status
Is your Driver's license, Permit or privilege to drive currently revoked, suspended, cancelled or denied?

Contact
Email: Phone:
No Email Provided No Phone Provided
Emergency Contact:
No Emergency Contact
Vision/Medical Questions
If applying for a driver's license or instructional permit do you wear glasses or contact lenses for driving?
Yes
Have you ever suffered with: Seizures, Fainting or Other Loss of Consciousness?
No
Do you wish to have your blood type displayed on the card?
No
Do you wish to have "Organ Donor" displayed on your license or ID?
Yes
Were you born on the same date (month/day/year) as any of your brothers and/or sisters and/or do you
have any identical siblings?
No
Do you want to donate $1 for the prevention of blindness?
No
Do you want to make a donation to the Georgia Student Finance Authority for educational aid to children
whose parents are or were public safety employees and were disabled or killed in the line of duty?
No

Proof Documents
I have reviewed the Real ID checklist for Non-US Citizens and will bring in the appropriate documents.
Which document will you provide to prove your Georgia residency?

Which secondary document will you provide to prove your Georgia residency?

Licensing History
Enter all of the U.S. States, including Georgia in which you hold or have held a commercial or non-commercial
Driver's License or Instructional Permit during the past ten (10) years.
Do you wish to transfer a valid out-of-state Commercial License to Georgia?
No
Do you plan to take a commercial skills test (road test) during your visit to DDS?
No
I certify that commercial motor vehicle I am taking the commercial driving skills test in is representative of
the type of vehicle I operate or expect to operate.
False
I certify that I do not have a commercial or non-commercial driver's license or instructional permit from
more than one state or jurisdiction.
True
Disqualifications
IMPORTANT: PLEASE READ THE FOLLOWING INFORMATION BEFORE ANSWERING QUESTIONS IN
THE SECTION
Convictions for certain offenses in Georgia or in any other state or country may result in the disqualification
of commercial driving privileges in Georgia by DDS. If you currently hold a CDL or CLP in Georgia when the
commercial disqualification becomes effective, you may not operate a commercial motor vehicle under any
circumstances during the disqualification period. If you do not currently hold a CDL or CLP in Georgia, you
will not be allowed to obtain a CDL or CLP during the disqualification period. An accumulation of certain
convictions can lead to permanent revocation of commercial driving privileges.
IMPORTANT: Disqualifications are imposed by DDS pursuant to Georgia statutes. In certain cases,
disqualifications imposed pursuant to Georgia statutes may be more severe than the disqualifications
required by regulations of the Federal Motor Carrier Safety Administration (FMCSA). In these situations, DDS
imposes the disqualifications required by Georgia law.
I certify that I have read and understand the information provided above.
True
Have you ever been convicted of or pled nolo contendere to any disqualifying offense?
No
Have you ever been convicted of or pled nolo contendere to more than one serious traffic violation (in any
vehicle) in the past three years?
No
I certify that I am not subject to any disqualification defined in 49 CFR §383.51 or any license suspension,
revocation, or cancellation pursuant to the laws of any State.
True
Self-Certification
Self-Certifying:
Non-Excepted Interstate - Multiple States, Medical Certificate Required
I certify that I will operate or expect to operate in interstate or foreign commerce, that I am subject to and
meet the FMCSA driver qualification requirements under 49 CFR part 391, and I am required to obtain a
medical examiner's certificate. I also certify that I do not have an impairment of an arm, foot or leg that
interferes with the normal tasks associated with the safe operation of a CMV. (Medical Card Required)
I acknowledge that Non-Excepted Interstate (NI) requires a valid Medical Certification Card.
True
Hazardous Materials
My application includes a request for issuance of a Hazardous Materials Endorsement (HME) extension. I
hereby swear or affirm that I have made application with the U.S. Transportation Security Administration
(TSA) for a Security Threat Assessment, but as of the date of this application, I have yet to receive a NO
DETERMINATION OF THREAT Assessment or a FINAL DETERMINATION OF THREAT Assessment. I fully
understand that upon expiration of the Georgia CDL with HME extension, I will not be eligible for any
further extensions of my HME.
No

Acknowledgement

Under penalty of law, I swear or affirm that I am a resident of the State of Georgia, and the information
provided on this form is true and correct. I understand that it is illegal to make false, fictitious, or fraudulent
statements on this form. I grant permission to the Department of Driver Services to verify information
furnished to the Department through the release of any and all applicant information to third parties which
shall include, but not be limited to the U.S. Department of Homeland Security or other public or private
entities wherein such disclosure of the information by the Department is not prohibited by law.

By checking this box and typing my name below, I am electronically signing my application.

DARREN EVAN WHEELER

Wait! You still need to come into a customer service center to finish your application.
Your Form for License/ID/Permit has been submitted. The form will remain on file for 60 days. If you do not
come into a customer service center within 60 days, a new Form for License/ID/Permit must be filled out. If
you provided an email address, you will receive a confirmation email.