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Last Name*

First Name*

Do you have middle name?*

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Middle Name

Do you have suffix?*

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Suffix Select a suffix Jr. Sr. II III IV V

Do you have maiden name (click yes if your current last name is different from your birth last name)?*

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Maiden Name

Date of Birth*

Gender*

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Height (enter feet part)* 1 2 3 4 5 6 7

Height (enter inches part)* 1 2 3 4 5 6 7 8 9 10 11

Weight (Lbs)*

Eye color*

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Hair color*

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Race*

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Asian or Pacific Islander

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Ethnicity*

Hispanic Origin

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Place of Birth: City*

Place of Birth: State*

Place of Birth: County

Place of Birth: Country*

Father's Last Name*

Mother's Maiden Name*

Residence Address*

City*

County*

State* --------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code*

Home Phone*

Email*

Is your mailing address the same as living address?*

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Please confirm that your residence address is:*

Single-Family Dwelling

Apartment

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Mailing Address

Mailing City

Mailing State --------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Mailing County

Mailing ZIP Code

First Emergency Contact Name*

First Emergency Contact Phone*

First Emergency Contact Address*

Second Emergency Contact Name

Second Emergency Contact Phone

Second Emergency Contact Address

Do you have Texas ID?*

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What is your ID type?*

Driver's License

State ID Card

Passport

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Other Government-Issued ID

ID number

Date Issued*

Are you a citizen of the United States*

Yes

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Do you have a health condition that may impede communication with a peace officer?*

Yes

No

Would you like to register as an organ donor?*

Yes

No

Do you own a motor vehicle that is required to be registered?*

Yes

No

Do you own a motor vehicle that is required to have liability insurance OR other proof of financial responsibility in compliance with the Motor Vehicle Safety Responsibility Act?*

Yes

No

Do you currently have or have you ever been diagnosed with or treated for any medical condition that may affect your ability to safely operate a motor vehicle?*

Yes

No

Do you have a mental condition that may affect your ability to safely operate a motor vehicle?*

Yes

No

Have you ever had an epileptic seizure, convulsion, loss of consciousness, or other seizure?*

Yes

No

Do you have diabetes requiring treatment by insulin?*

Yes

No

Do you have any alcohol or drug dependencies that may affect your ability to safely operate a motor vehicle or have you had any episodes of alcohol or drug abuse within the past two years?*

Yes

No

Within the past two years have you been treated for any other serious medical conditions?*

Yes

No

Have you EVER been referred to the Texas Medical Advisory Board for Driver Licensing?*

Yes

No

If you are U.S. citizen, would you like to register to vote?*

Yes

No

Are you a veteran?*

Yes

No

Is your driving license or driver privilege CURRENTLY or EVER been suspended, revoked, cancelled, denied or disqualified in ANY state?*

Yes

No