Unformatted text preview: driving privilege now suspended, disqualified, canceled, denied or revoked?
Do you have a license from more than one state or jurisdiction? My vehicle is registered in another state (indicate which state): State I am active duty military or family member. I am an out-of-state student or family member. I want to show a medical alert condition on my license/ID (must submit physician or registered nurse practitioner statement). I also want this alert maintained on my permanent computer record. (If not checked, when you reapply or request a duplicate, the alert will not
appear on your license/ID unless you resubmit a physician or registered nurse practitioner statement.) I consent to the release of personal information contained in my driver license and vehicle record. I understand that this is not a one-time consent that
applies only to a specific individual or organization, but is instead a general consent that applies to all requests from any and all individuals or
organizations for any purpose, until revoked by me in writing. Consent for a vehicle record applies to all owners. Yes No Do you have...
View Full Document
- Spring '07
- Driver's license, driver license, MVD Agent Signature, MVD Agent