GEORGIA DEPARTMENT OF DRIVER SERVICES

FORM FOR LICENSE/ID/PERMIT

SECTION A: FORM INFORMATION

Do you now have or have you ever had a Georgia Driver’s License, Identification Card or Permit? Yes
✘ No
GEORGIA DRIVER’S LICENSE/ID/PERMIT#: SOCIAL SECURITY #:
064200869 055-62-3499
LEGAL FIRST NAME: MIDDLE OR MAIDEN NAME:
KAMEL
LEGAL LAST NAME: SUFFIX: ☐ Jr. ☐ Sr. ☐ II ☐ III ☐ IV
Jones
MAILING ADDRESS (STREET ADDRESS OR PO BOX, APT #, CITY, STATE, ZIP CODE):
3510 BUFORD HWY. NE, APT. U13, BROOKHAVEN, GA 30329
RESIDENTIAL ADDRESS - If different from MAILING ADDRESS above (STREET ADDRESS, APT #, CITY, STATE, ZIP CODE

MAILING
PHONE #:ADDRESS above (STREET ADDRESS, APT#:#, CITY, STATE, ZIP CODE): EMAIL:
Alt. Phone
+1 (770) 912-5187 choice1@gmx.us
BIRTH
12 31 1968
DATE: ______/______/________ GENDER: ✘ M F 5 Feet ____
HEIGHT: ____ 6 Inches 180
WEIGHT: ________Pounds BROWN
EYE COLOR: __________
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SECTION B: LEGAL STATUS

By completing this form and signing the back, I swear that one of the following is true and accurate pursuant to O.C.G.A. §50-36-1.
☐ I am a United States citizen, OR
☐
✘ I am a legal permanent resident, OR
☐ I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act and lawfully present in the United States.
Alien Registration number OR I-94 number for non-citizens: _____________________________________________________________________________
SECTION C: ANSWER EACH QUESTION
1 What can we help you with today? 
✘ License/Permit  Identification Card  Reinstatement
Have you ever had a GA, Out-of-State or Foreign Driver’s License, Identification Card or Permit? Yes No
✘

If Yes, please list the most recent (a)State or Country and (b)Name on Card:
2
1. (a) ____________________ (b) ____________________________
2. (a) ____________________ (b) ____________________________
Is your Driver’s License, Permit or privilege to drive currently revoked, suspended, cancelled or denied? Yes No
✘
3
mm dd yyy
If Yes, list most recent: State: ______________ Action: ____________________Date of Action: ______/______/________
y
Did you bring your GA, Out-of-State or Foreign Driver’s License, Identification Card or Permit with you today? Yes No
✘
4
If No, why? ☐ A Law Enforcement/Official has it; ☐ It is damaged, lost or stolen; ☐
✘ New Customer
5 Do you wear prescription glasses or contact lenses for driving? Yes No
✘

Have you ever suffered with: Seizures, Fainting or Other Loss of Consciousness? Yes No
✘
6
mm dd yyy
If Yes, please list Date of Last Episode: ______/______/________
y
Were you born on the same date (month/day/year) as any of your brothers and/or sisters AND/OR do you have
Yes No
✘
7 any identical siblings?
If Yes, please list their full name(s): __________________________________________________________________________

8 Would you like to have “Organ Donor” displayed on your license or ID? Yes No
✘

9 Would you like to donate $1 to the Georgia Drive for Sight Program for the prevention of blindness? Yes No
✘

Would you like to donate to the Georgia Student Finance Authority for educational aid to children whose parents
10
are/were public safety employees and were disabled or killed in the line of duty?  $1  $5  $10 Yes No
✘

Are you a male U.S citizen or immigrant under age 26? Yes No
✘
11
If Yes, have you registered with the Selective Service System? Yes No
The Georgia Department of Driver Services (DDS) is required to ask all male U.S. citizens and immigrants, 18 – 25 years old, if they are registered with the U.S. Selective Service System (SSS). The DDS will report all
responses to the SSS. You may be contacted by that agency as a result of your response. If you are not registered with the SSS, your signature constitutes consent to be registered. Please contact the SSS to verify
registration. O.C.G.A. §40-5-8.

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 SECTION D: VOTER REGISTRATION
The office where the registration application was submitted and any failure to register will remain confidential and will be used
for voter registration purposes only.
1 NOTE: All information provided on this form will be used for voter registration purposes, unless you opt-out.  Opt-Out
2
RACE: ☐ American Indian ☐ Asian/Pacific Islander ☐ Black ☐ Hispanic/Latino ☐ Multiracial ☐ White ☐ Other ☐ Refuse
Your signature in this section serves as an attestation under penalty of perjury that all of the following requirements have been met:
✓ I am a citizen of the United States.
✓ I am at least 17 ½ years of age.
✓ I reside at the address listed on this form.
✓ I am eligible to vote in Georgia.
✓ I am not serving a sentence for conviction of a felony involving moral turpitude. (You are serving a sentence if you are on
probation or parole from your conviction of a felony involving moral turpitude.)
✓ I have not been judicially declared mentally incompetent, or if such declaration has been made, the disability has been removed.

WARNING: Any person who registers to vote knowing that such person does not possess the qualifications required by law, who registers
under any name other than such person’s own legal name or who knowingly gives false information in registering, shall be guilty of a felony.
The penalties for false registration are up to ten years in prison and up to a $100,000.00 fine pursuant to O.C.G.A. § 21-2-561.

Customer’s Signature X Date _______/______/_________

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SECTION E: OTHER (Optional Information)

1
EMERGENCY CONTACT
Name: Phone Number:.
Do you want your blood type displayed on your card? Yes No
2 If Yes, please check blood type: ☐ A + ☐ A - ☐ B + ☐ B - ☐ AB + ☐ AB - ☐ O + ☐ O -
NOTE: This information is voluntary and may be used to assist medical personnel. You agree to hold DDS harmless for any/all injuries that may occur from using this information.
SECTION F: REQUIRED SIGNATURE
This form can be notarized at the Customer Service Center for free.

Under penalty of law, I swear or affirm that I am a resident of the State of Georgia, and that any and all 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 customer 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.

NOTARY
SEAL
Customer’s Signature X Date _______/______/_________
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Date _______/______/_________
Notary’s Signature mm dd yyyy

DDS-23 MIR - Revised 01/01/2018 Please visit us online at www.dds.georgia.gov Page 2 of 2