OFF

ICE O

F THE TAX COLLECT

OR

L A K E COU N T Y

LAKE COUNTY TAX COLLECTOR

DRIVER LICENSE & ID CARD APPLICATION

OFFICE HOURS & LOCATIONS

PG 1 of 2LCTC Rev. 04/20

PLEASE CONTINUE TO PAGE 2

OFFICE USE ONLY BELOW THIS LINE

FEDERAL REAL ID REQUIREMENTS FOR IDENTITY VERIFICATION (ALL TRANSACTIONS)

The Federal Real ID Act requires documentation that establishes your identity when applying for a Florida driver license or ID card. A STAR on your Florida driver license or ID card means you are Real ID compliant. • CURRENT FLORIDA DRIVER LICENSE OR ID CARD WITH STAR:

• FIRST TIME FLORIDA LICENSE OR ID CARD • CURRENT FLORIDA LICENSES OR ID CARDS WITHOUT A STAR (Customers born on or before 1945 that cannot obtain a birth certificate may present a secondary identification)

• YOUR NAME HAS CHANGED FROM YOUR BIRTH CERTIFICATE NAME (See Box #2 below)

Address Change Name Change• Bring two proofs of your new address (see Box #3 below) • Bring your official name change document (see Box #2 below)

Date of TLSAE Completion: Vision: Pass/Fail Date:Restrictions:

Transaction Processed: Driver License ID Card Reinstatement Only Temporary CDL Permit Docs Needed Failed Written Update CDL Medical Card Failed Driving Transcripts

Form Reviewed/Processed by LCTC Initials:

1 - IDENTIFICATION 2 - NAME CHANGE 3 - YOUR ADDRESS 4 - SOCIAL SECURITY

BRING ONE: • US Passport (expired is ok) • Original US Birth Certificate• Certified US Birth Certificate • Naturalization Certificate • INS (USCIS) Documentation

Does the name match your license or ID card? If not, don’t forget your name change documents; see box #2 on right

BRING ONE: • Social Security Card or Stub • W-2/1099 Form (pre-printed) • Pay Stub • Proof must list full name and full Social Security #.

Name changes must be reported to Social Security at least 24 hours prior to visiting our office. socialsecurity.gov 800.772.1213

BRING ALL THAT APPLY: • Original Marriage Certificate • Certified Marriage Certificate• Divorce Decree • Court Order

This is only required when a prior name (or maiden name) is shown on the identification document provided; see box #1 on left

BRING TWO from Residence: • Car or Boat Registration • Utility Bill or Credit Card Bill • Bank Statement • Voter Registration Card • Lease/Rental Agreement • Deed, Mortgage • Insurance Policy/Card

You can fill out a self-certification form in place of a second piece of mail. Must show name and address (not a post office box).

1. Yes No Have you ever been licensed in any US state(s) other than your current driver license in your lifetime?

If yes, list the most recent state(s): ____________________________________

2. Yes No Have you ever been adjudged by a court of law to be mentally incapacitated, suffering from any mental disorder or disease?

3. Yes No Do you have any physical or mental disabilities that could affect your driving? Any epilepsy, fainting, or dizzy spells within the last 2 years?

4. Yes No Are you addicted to drugs or intoxicants?

5. Yes No You can save the lives of EIGHT people and improve the lives of many more by being an organ donor. Say “YES” today to become/remain an organ donor!

6. Yes No Are you insulin dependent? If yes, would you like “Insulin Dependent” indicated on your license?

TRANSACTION DATE

Q-FLOW CASE ID # (Not Ticket #)

MONTH DAY YEAR

PG 2 of 2LCTC Rev. 04/20

OATH AND ACKNOWLEDGMENT (Required per s. 322.08, F.S.)

Under penalty of perjury, I (the applicant) swear or affirm that the information given by me in this application is true and correct. I understand that a person who knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of their official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083, Florida Statutes.

Signature of Applicant: Date:

This information must match your identification documents presented and will be used to create your Florida Driver License or ID Card.

FULL FIRST NAME ETHNICITY (Required as part of applicant’s description per s. 322.08, F.S.)

FULL MIDDLE NAME

FULL LAST NAME

SUFFIXJr., Sr., III

CURRENT DRIVER LICENSE NUMBER OR ID CARD (AREA CODE) PHONE NUMBER

COUNTRY OF BIRTH STATE OF BIRTH

STATE

HEIGHTFeet Inches

DATE OF BIRTHMonth Day Year

ADDRESS WHERE YOU LIVE (If different than above)

ADDRESS WHERE YOU RECEIVE MAIL

Street Address (No PO Box)

Street Address or PO Box

CITY

CITY

STATE

STATE

ZIP

ZIP

Asian Black Hispanic Native American White Other

SEXMale Female

VOTER’S REGISTRATION APPLICATION (s. 97.057, F.S.). Providing this information is voluntary. You must be a U.S. Citizen; be a Florida resident; be at least 18 years old; however, a customer who is at least 16 years old can pre-register to vote.

I decline (do not want) or I am ineligible to apply for a Florida voter’s registration card.

1. Select ONE of the following options: Note: Each driver license or ID card application serves as an application for voter registration unless otherwise indicated: By completing the information below, you agree to use your residential address (above) and signature (below)for voter registration purposes.

Current I am currently registered to vote in Florida and I don’t need to make any changes (skip to ‘Oath and Acknowledgment’). Change I need to change the following info on my Florida voter’s registration card: Address Party Name New I would like to apply for a first-time Florida voter’s registration card. If currently registered to vote in another state, provide your

out-of-state Address: City:

State: Zip:

2. Yes No By answering ‘Yes’, you are affirming you have NOT been adjudicated mentally incapacitated with respect to voting OR, if you have, your right to vote has been restored. Required per s. 97.041, F.S.

3. Yes No By answering ‘Yes’, you are affirming you are NOT a convicted felon, OR, if you are, your right to vote has been restored. Required per s. 97.041, F.S. NOTE: Your voting rights must be restored in order to be eligible to apply for a Florida voter’s registration.

4. Yes No Do you require voting assistance?

5. Yes No Are you interested in being a poll worker? A poll worker prepares the precinct by setting up voting equipment and providing voters with appropriate ballots. Refer to LakeVotes.com or call 352.343.9734 for details.

6. Party Affiliation check one box only Democrat Republican No Party Affiliation Minor party (party name):

7. Yes No Are you Active Duty Military or Merchant Marine?

8. Yes No Are you the dependent of Active Duty Military or Merchant Marine?

9. Yes No Are you a US Citizen currently residing outside of the US?

10. Yes No I understand that I can provide my email address and receive sample ballots and other voting information from the Supervisor of Elections office by visiting LakeVotes.com, calling 352.343.9734 for details.

Email address:

11. INITIAL HERE I do solemnly swear (or affirm) that I will protect and defend the Constitution of the United States and the Constitution of the State of Florida, that I am qualified to register as an elector under the Constitution and laws of the State of Florida, and that all information provided in this application is true.

This page is include for use if you are a minor and are using your parents mail in their name, or if you are using someone else’s mail to

certify your address.

DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES

DIVISION OF MOTORIST SERVICES

2900 Apalachee Parkway

Neil Kirkman Building - Tallahassee, FL 32399

C E R T I F I C A T I O N O F A D D R E S S

Date

I do hereby certify that:

Name (First) (Middle) (Last)

Date of Birth

Resides at:

Street, Apartment

City State Zip Code

SPECIAL CONDITIONS:

Self Certification Released from Incarceration**

Homeless* Other

Signature of Addressee/Customer Print Name of Addressee/Customer Date

INSTRUCTIONS:

A Certification of Address form completed and signed by the customer is accepted as proof of residential address, providing

it is accompanied by:

o One proof of residential address in the customer’s name or;

o One proof of residential address in the name of the person with whom the customer resides. ***

* Homeless customers may present a letter listing the customer’s name from a shelter, public assistance agency

representative along with the completed Certification of Address form.

** Customers released from incarceration may present an Address Verification Letter from the Department of Corrections

(with an Inmate Identification Card and Certificate of Discharge) along with the completed Certification of Address form.

*** A list of documents that can be used as proof of residential address can be found at

www.GatherGoGet.com.

HSMV 71120 (Rev 04/13)

DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES DIVISION OF MOTORIST SERVICES

2900 Apalachee Parkway Neil Kirkman Building - Tallahassee, FL 32399

S E L F - C E R T I F I C A T I O N O F

S O C I A L S E C U R I T Y N U M B E R

Date

I do hereby certify that: Name (First) (Middle) (Last)

Date of Birth Social Security Number ________________________

Signature of Customer Print Name of Customer Date

INSTRUCTIONS:

A Self-Certification of the social security number form that is completed and signed by the customer is accepted as proof of the social security number, providing the number verifies through the Social Security Administration Verification System. If the social security number presented on this form does not verify, customer will need to provide proof of the social security number for issuance of a Florida driver license or identification card. Note: A list of documents that can be used as proof of the social security number can be found at http://www.gathergoget.com/.

Only complete the next Pages for CDL Commercial Driver License Transactions

David Jordan, Lake County Tax Co l lector

Commercial Driver License Application Must be accompanied by the Application for a Driver License or ID Card form

SECTION 1 – MARK THE TYPE OF TRANSACTION YOU ARE HERE TO COMPLETE

c I need to renew, replace or be issued a CDL license. Proceed to Section 2. c I am here for written CDL testing and/or a temporary CDL permit Proceed to Section 2..

c I am here to update my CDL medical certification on file. Proceed to Section 2. NOTE: Updates can be done online, eliminating a visit to the

Lake County Tax Collector’s Office. Visit https://services.flhsmv.gov/CDLMedCert/. c Would you like to receive email or text notification from the Department regarding the upcoming expiration of your Medical Certification?

Customer Cell Phone#: Customer Email: c I want to downgrade from a CDL to a regular operator’s license (Class E). NOTE: When downgrading, all CDL testing information

will remain on file as long as a valid Florida license is maintained. Skip to Section 4. c I am here to clear a CDL disqualification. Proceed to Section 2.

SECTION 2 – MEDICAL CERTIFICATION: DECLARE YOUR CATEGORY

ALL CDL applicants are required to self-certify into one of the categories below per § 383.71 Federal Motor Carrier Safety Regulations. For complete category details, visit fmcsa.dot.gov/faq.

MARK ONE OF THE FOLLOWING CATEGORIES:

c CATEGORY A: NON-EXCEPTED INTERSTATE (MOST COMMON) **MEDICAL CARD REQUIRED** I am 21 years of age or older. I

operate or expect to operate in interstate commerce and am required to maintain federal medical certification. If you operate in both interstate AND intrastate, you must select this category. Interstate is defined as: commerce between 2 states or a foreign country; between two places within a state but crosses into another state or foreign country; between two places within a state, but cargo/passengers are part of a trip that began or will end in another state or foreign country.

c CATEGORY B: EXCEPTED INTERSTATE - I am 21 years of age or older. I operate or expect to operate in interstate commerce, but

engage exclusively in operations that qualify me for exception from the requirement to maintain federal medical certification. Common interstate exceptions: transportation by a federal, state or local government; occasional transport of personal property (personal use/without compensation); transport of medical patients or human corpses; emergency operations; custom harvesting; beekeeping.

c CATEGORY C: NON-EXCEPTED INTRASTATE **MEDICAL CARD REQUIRED** - I operate or expect to operate only in intrastate commerce and am required to maintain State of Florida medical certification. Intrastate is defined as: transporting goods or passengers without crossing a state border and not for any portion of a direct shipment into or out of the state. This also includes most school bus drivers. Under 21 years old or is insulin dependent or does not meet 20/40 in each eye with best correction.

c CATEGORY D: EXCEPTED INTRASTATE - I operate or expect to operate only in intrastate commerce, but engage exclusively in operations that qualify me for exception from State of Florida medical certification. Common Intrastate exceptions: transport of agriculture/forestry products between the farm/place of harvest and a market or first place of storage; driving commercially for an electric/phone company within 200 miles of where vehicle is based; operation of a private school bus seating less than 24 passengers; operation as a driver/salesman within 100 miles of the workplace, conviction free. Under 21 years old or is insulin dependent or does not meet 20/40 in each eye with best correction.

W UNEMPLOYED - CDL holders can no longer claim exemption from medical certification because they are not employed or currently operating in non-excepted interstate or intrastate commerce. If not specifically included in category B or D above, you must maintain your medical certification or downgrade to a non-commercial license.

IMPORTANT: If you self-certify in CATEGORY A or C above, you are required to show a medical card. It must be completed in full by a qualified physician and must include the national registry ID #. It must be legible and cannot contain any alterations, cross-outs, white-out or any other corrections. See fmcsa.dot.gov for details about medical card requirements. If you are unable to provide an acceptable medical card, you will be required to obtain a new card.

By entering the expiration date from the medical card and initialing below, I hereby acknowledge that my medical card meets the federal and/or State of Florida requirements. Medical Card Expiration Date: Applicant’s Initials: ________ Proceed to Section 3

SECTION 3 REQUIRED APPLICATION QUESTIONS

This section must be completed if you are RENEWING, REPLACING OR BEING ISSUED A CDL LICENSE.

1.

c Yes c No

Are you physically qualified to operate a commercial motor vehicle per §391.41 of the Federal Motor Carrier

Safety Regulations? “Physically qualified” includes but is not limited to having both feet, legs, hands and arms, as well as having no established clinical diagnosis or medical history of a condition or disease, or other impairment that would interfere with your ability to safely operate a commercial motor vehicle. For a

complete list of physical qualifications, visit fmcsa.dot.gov/

2. c Yes c No Are you applying for employment or are you currently employed with a public or private school system that requires you to hold a CDL license?

If YES, do you have your public/private school employment ID card or letter from your employer? This is required in order to qualify for a reduced fee for an original issuance or a renewal. c Yes c No

3. c Yes c No I certify that the motor vehicle that I used to take the CDL driving skills test represents the type of motor 4.

c Yes c No

vehicle I operate or expect to operate. If NO, you may be subject to additional testing.

Have you been licensed in any state other than Florida in the last 10 years? If yes, what state(s)? Include license #’s (if known):

Proceed to Section 4

SECTION 4 – WARNINGS AND OATH (MUST BE COMPLETED BY ALL APPLICANTS)

ALL APPLICANTS must complete this section.

You hereby acknowledge the following:

c It is your responsibility to determine the appropriate selection and whether an exception applies to you. Severe fines, penalties and

incarceration are possible for violators who operate under an incorrect selection, do not maintain certification or provide any false/incorrect information to obtain a CDL. We strongly suggest that you seek legal advice, the advice of your employer or consult the appropriate state and federal regulations. Drivers are urged to visit flhsmv.gov and fmcsa.dot.gov/ for information and regulations.

c If I verbally declared that I am an insulin dependent diabetic, I acknowledge that an intrastate restriction (2) will be added to

my CDL license. This statement does not apply if you did not verbally declare that you are an insulin dependent diabetic.

c You must review your driver license before you leave the office and inform staff of any error (endorsements, restrictions, spelling/address corrections, license types, etc.) so that they can be corrected. Once you leave the office, the transaction cannot be voided or cancelled and corrections/changes will be subject to standard reissue fees.

Under penalty of perjury I (the applicant) swear or affirm that the information given by me in this application is true and correct.

Printed Name of Applicant:

Signature of Applicant: Date:

HANDBOOKS

David Jordan, Lake County Tax Co l lector STAY CONNECTED TO THE TAX COLLECTOR’S OFFICE!

Important updates, office locations and other information is just a click away.

• Visit our website laketax.com To make an appointment for CDL Exams or CDL HazMat fingerprinting • Get driver handbooks at https://www.flhsmv.gov/resources/handbooks-manuals/ or scan the QR code on the right with your

smartphone Revised 12/5/2018

DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES DIVISION OF MOTORIST SERVICES

Commercial Driver’s License Document Verification Certification

Date:

Customer Name or DL #:

I do hereby certify that, I have verified and/or processed the documents involved in the Commercial Driver’s License/Commercial Learner’s Permit licensing issuance in accordance with; Federal Motor Carrier Safety Administration’s (FMCSA), Commercial Driver’s License Standards; §383.73: (m) Document Verification.

Office Use Only Below

Signature: Examiner ID:

Signature: Examiner ID:

CDL Verification Certification DL15-014 September 22, 2017 (Page 4)