DMV USE OUT OF STATE CHANGE ENDORSEMENT/
NEW RETEST EXCHANGE
ONLY TRANSFER RESTRICTION
APPLICATION FOR A NON-COMMERCIAL
LEARNER PERMIT AND/OR DRIVER LICENSE STATE OF CONNECTICUT
R-229 REV. 7-2013 DEPARTMENT OF MOTOR VEHICLES
On The Web At ct.gov/dmv
INSTRUCTIONS: Complete 1-16, then present
1. Required Identification Documents & Proof of Connecticut
Residency: see "Acceptable Forms of ID" at ct.gov/dmv
2. 16 and 17 year olds: Certificate of Parental Consent Form 2D
LEARNER PERMIT NUMBER DATE OF ISSUE
(if not accompanied by authorized individual)
3. Applicable Fees
1. APPLICANT'S NAME (Last, First, Middle, Suffix) 2. SEX 3. DATE OF BIRTH 4. HEIGHT 5. COLOR OF EYES
M F ft. in.
6. MAILING ADDRESS (No., Street, City or Town, State, Zip Code) 7. RESIDENCE ADDRESS (If different)
8. US CITIZEN? If "NO", list ALIEN REGISTRATION NO. 9. CONNECTICUT 10. DO YOU WANT TO BE IN THE ORGAN/TISSUE DONOR DAYTIME PHONE NO.
RESIDENT? REGISTRY? If yes, you are agreeing to be a donor
Yes No and the designation will be on your
Yes No Yes No ( )
license.
11. SOCIAL SECURITY NUMBER 12. LIST ANY OTHER NAMES EVER USED (Alias, Maiden, etc)
QUESTIONS YES ( ) NO ( )
13. Have you previously failed a driver's license FAILED LOCATION/DATE
examination in Connecticut? KNOWLEDGE VISION ROAD SKILLS
14. Do you now, or have you ever held a Connecticut Learner Permit, IF YES, IN WHAT YEAR(S)? CONNECTICUT PERMIT, LICENSE OR ID NO. (9 digits)
License or Non-Driver Identification card?
15. Do you now hold or have you ever held an operator's license or STATE, DRIVER LICENSE OR ID. NO. NO. OF YEARS
identification card from another state?
IN WHAT STATE(S)?
16. Is your privilege to operate a motor vehicle suspended or subject to
suspension in Connecticut or in any other state?
Section 14-36l of the Connecticut General Statutes requires the Commissioner to transmit my
SELECTIVE information to the Selective Service System. By signing and submitting this application, I consent I hereby certify that I do not
to be registered with the Selective Service System, provided I am at least age 16 but under age MEDICAL have any health or vision
SERVICE 26 and meet the criteria for registration in accordance with the Military Selective Service Act. If I problems or conditions that
CERTIFICATION
CONSENT am under age 18, I understand that my information will be transmitted to Selective Service but I prevent me from driving safely.
will not be registered until I reach age 18.
The information provided to the Commissioner of Motor Vehicles herein is SIGNATURE OF APPLICANT DATE SIGNED
subscribed by me, under penalty of false statement, in accordance with
CERTIFICATION the provisions of Section 14-110 and 53a-157b of the Connecticut General
BY APPLICANT Statutes. I understand that if I make a statement which I do not believe to
be true, with the intent to mislead the Commissioner, I will be subject to
prosecution under the above-cited laws. X
DO NOT WRITE BELOW THIS LINE - OFFICE USE ONLY
PROOF OF TYPE OF ACCEPTABLE I.D. SHOWN EXAMINER INITIAL STAMP NO.
I.D. SCANNED FIRST VISIT
IDENTIFICATION
FULL LEGAL If different than entered in name section above (# 1)
NAME
PARENTAL I hereby request that a learner's permit RELATIONSHIP TO MINOR SIGNED (Authorized Consenter) CONSENTER'S LIC. NO. OR OTHER I.D.
CONSENT and/or license be issued to the minor
AGE 16 OR 17 ONLY filing this application. X
VISION VISUAL AID USED RESULTS AGENTS INITIALS PUNCH NO. AND PUNCH
SCREENING NONE GLASSES/CONTACTS PASSED FAILED
RESULTS
KNOWLEDGE TEST RESULTS IDENTIFICATION DOCUMENTS APPLICANT INITIALS
RETURNED
TEST COMPUTER WRITTEN ORAL WAIVED PASSED FAILED
ISSUE PERMIT WITH CORRECTIVE LENSES
PERMIT ISSUE LEARNER PERMIT ISSUE MOTORCYCLE PERMIT
(B-RESTRICTION)
AGENT I hereby certify that I have examined the applicant's identity SIGNED (Agent) PUNCH NO. AND PUNCH DATE SIGNED
documents and the test results stated herein are true and
CERTIFICATION correct. X
CLASSROOM SCHOOL NAME COMMERCIAL SCHOOL LICENSE NO. DRIVER EDUCATION CERTIFICATE NO.
DRIVER INSTRUCTION
TRAINING PRACTICE SCHOOL NAME (If same as above print "same") COMMERCIAL SCHOOL LICENSE NO. DRIVER EDUCATION CERTIFICATE NO.
DRIVING
I hereby subscribe and certify under penalty of false statement, in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes that I
understand that if I make a statement, which I do not believe to be true, with the intent to mislead the Commissioner I will be subject to prosecution under the above-cited laws, that,
HOME I am qualified under Section 14-36, of the Connecticut General Statutes, over 20 years of age, have no suspensions within the previous 4 years and the Applicant has received the
required training, including the equivalent of 22 hours classroom training; 40 hours on-the-road instruction; the 8 hours Safe Driver course, including a 2 hour Parent Training, as
TRAINING/ supported by a parent log and/or driving school certificate.
COMMERCIAL 1 2 3 SIGNATURE OF INSTRUCTOR (Home Training/Commercial) OPERATOR LICENSE NUMBER OR
SCHOOL LICENSE NUMBER
TRAINING Home Training Comm/Sec and Home Comm/Sec Only
22 hr class equiv 30 hrs class/minimum 30 hrs class
CERTIFICATION 40 hr on-the-road 8 hr safe driving plus home 40 hrs on-the-road
8 hr safe driving training 40 hrs on-the-road X
NO FEE SPECIAL EQUIPMENT
ROAD TEST WAIVED PASSED FAILED U.S.
SERVICE
AND LICENSE NON-COMMERCIAL CLASS ENDORSEMENT RESTRICTIONS (Circle All Applicable)
INFORMATION
D M Q B C D E F G R U
AGENT I hereby certify that I have verified the applicant's SIGNED (Agent) PUNCH NO. AND PUNCH DATE SIGNED
identity and the test results stated herein are true
CERTIFICATION and correct.
DISTRIBUTION: White - Branch Office Canary - Agent Pink - Examiner
DMV USE OUT OF STATE CHANGE ENDORSEMENT/
NEW RETEST EXCHANGE
ONLY TRANSFER RESTRICTION
APPLICATION FOR A NON-COMMERCIAL
LEARNER PERMIT AND/OR DRIVER LICENSE STATE OF CONNECTICUT
R-229 REV. 7-2013 DEPARTMENT OF MOTOR VEHICLES
On The Web At ct.gov/dmv
INSTRUCTIONS: Complete 1-16, then present
1. Required Identification Documents & Proof of Connecticut
Residency: see "Acceptable Forms of ID" at ct.gov/dmv
2. 16 and 17 year olds: Certificate of Parental Consent Form 2D
LEARNER PERMIT NUMBER DATE OF ISSUE
(if not accompanied by authorized individual)
3. Applicable Fees
1. APPLICANT'S NAME (Last, First, Middle, Suffix) 2. SEX 3. DATE OF BIRTH 4. HEIGHT 5. COLOR OF EYES
M F ft. in.
6. MAILING ADDRESS (No., Street, City or Town, State, Zip Code) 7. RESIDENCE ADDRESS (If different)
8. US CITIZEN? If "NO", list ALIEN REGISTRATION NO. 9. CONNECTICUT 10. DO YOU WANT TO BE IN THE ORGAN/TISSUE DONOR DAYTIME PHONE NO.
RESIDENT? REGISTRY? If yes, you are agreeing to be a donor
Yes No and the designation will be on your
Yes No Yes No ( )
license.
12. LIST ANY OTHER NAMES EVER USED (Alias, Maiden, etc)
QUESTIONS YES ( ) NO ( )
13. Have you previously failed a driver's license FAILED LOCATION/DATE
examination in Connecticut? KNOWLEDGE VISION ROAD SKILLS
14. Do you now, or have you ever held a Connecticut Learner Permit, IF YES, IN WHAT YEAR(S)? CONNECTICUT PERMIT, LICENSE OR ID NO. (9 digits)
License or Non-Driver Identification card?
15. Do you now hold or have you ever held an operator's license or STATE, DRIVER LICENSE OR ID. NO. NO. OF YEARS
identification card from another state?
IN WHAT STATE(S)?
16. Is your privilege to operate a motor vehicle suspended or subject to
suspension in Connecticut or in any other state?
Section 14-36l of the Connecticut General Statutes requires the Commissioner to transmit my
SELECTIVE information to the Selective Service System. By signing and submitting this application, I consent I hereby certify that I do not
to be registered with the Selective Service System, provided I am at least age 16 but under age MEDICAL have any health or vision
SERVICE 26 and meet the criteria for registration in accordance with the Military Selective Service Act. If I problems or conditions that
CERTIFICATION
CONSENT am under age 18, I understand that my information will be transmitted to Selective Service but I prevent me from driving safely.
will not be registered until I reach age 18.
The information provided to the Commissioner of Motor Vehicles herein is SIGNATURE OF APPLICANT DATE SIGNED
subscribed by me, under penalty of false statement, in accordance with
CERTIFICATION the provisions of Section 14-110 and 53a-157b of the Connecticut General
BY APPLICANT Statutes. I understand that if I make a statement which I do not believe to
be true, with the intent to mislead the Commissioner, I will be subject to
prosecution under the above-cited laws. X
DO NOT WRITE BELOW THIS LINE - OFFICE USE ONLY
PROOF OF TYPE OF ACCEPTABLE I.D. SHOWN EXAMINER INITIAL STAMP NO.
I.D. SCANNED FIRST VISIT
IDENTIFICATION
FULL LEGAL If different than entered in name section above (# 1)
NAME
PARENTAL I hereby request that a learner's permit RELATIONSHIP TO MINOR SIGNED (Authorized Consenter) CONSENTER'S LIC. NO. OR OTHER I.D.
CONSENT and/or license be issued to the minor
AGE 16 OR 17 ONLY filing this application. X
VISION VISUAL AID USED RESULTS AGENTS INITIALS PUNCH NO. AND PUNCH
SCREENING NONE GLASSES/CONTACTS PASSED FAILED
RESULTS
KNOWLEDGE TEST RESULTS IDENTIFICATION DOCUMENTS APPLICANT INITIALS
RETURNED
TEST COMPUTER WRITTEN ORAL WAIVED PASSED FAILED
ISSUE PERMIT WITH CORRECTIVE LENSES
PERMIT ISSUE LEARNER PERMIT ISSUE MOTORCYCLE PERMIT
(B-RESTRICTION)
AGENT I hereby certify that I have examined the applicant's identity SIGNED (Agent) PUNCH NO. AND PUNCH DATE SIGNED
documents and the test results stated herein are true and
CERTIFICATION correct. X
CLASSROOM SCHOOL NAME COMMERCIAL SCHOOL LICENSE NO. DRIVER EDUCATION CERTIFICATE NO.
DRIVER INSTRUCTION
TRAINING PRACTICE SCHOOL NAME (If same as above print "same") COMMERCIAL SCHOOL LICENSE NO. DRIVER EDUCATION CERTIFICATE NO.
DRIVING
I hereby subscribe and certify under penalty of false statement, in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes that I
understand that if I make a statement, which I do not believe to be true, with the intent to mislead the Commissioner I will be subject to prosecution under the above-cited laws, that,
HOME I am qualified under Section 14-36, of the Connecticut General Statutes, over 20 years of age, have no suspensions within the previous 4 years and the Applicant has received the
required training, including the equivalent of 22 hours classroom training; 40 hours on-the-road instruction; the 8 hours Safe Driver course, including a 2 hour Parent Training, as
TRAINING/ supported by a parent log and/or driving school certificate.
COMMERCIAL 1 2 3 SIGNATURE OF INSTRUCTOR (Home Training/Commercial) OPERATOR LICENSE NUMBER OR
SCHOOL LICENSE NUMBER
TRAINING Home Training Comm/Sec and Home Comm/Sec Only
22 hr class equiv 30 hrs class/minimum 30 hrs class
CERTIFICATION 40 hr on-the-road 8 hr safe driving plus home 40 hrs on-the-road
8 hr safe driving training 40 hrs on-the-road X
NO FEE SPECIAL EQUIPMENT
ROAD TEST WAIVED PASSED FAILED U.S.
SERVICE
AND LICENSE NON-COMMERCIAL CLASS ENDORSEMENT RESTRICTIONS (Circle All Applicable)
INFORMATION
D M Q B C D E F G R U
AGENT I hereby certify that I have verified the applicant's SIGNED (Agent) PUNCH NO. AND PUNCH DATE SIGNED
identity and the test results stated herein are true
CERTIFICATION and correct.
DISTRIBUTION: White - Branch Office Canary - Agent Pink - Examiner
