STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
ct.gov/dmv We'd like to hear from you!
Date: 2/8/2021 CONGRATULATIONS
ALLEN LIU
YOU HAVE SUCCESSFULLY SCHEDULED YOUR LEARNER PERMIT VISION AND KNOWLEDGE TEST APPOINTMENT
ALL DOCUMENTS PRESENTED TO THE DMV MUST BE ORIGINAL OR CERTIFIED COPIES.
PHOTOCOPIES WILL NOT BE ACCEPTED.
BE PREPARED. Bring the following REQUIRED documents with you!
Please refer to the document checklist on page 3 or at ct.gov/dmv/RealID for a complete list of acceptable documents to
answer 1-5 below.
1. IDENTITY: You must present two forms of identification. At least one of the documents must be from the primary document list.
My primary document I will present is: , my 2nd is
2. SOCIAL SECURITY NUMBER: You must present one of the following to prove your social security number (SSN): Social Security
Card, 1099 or W-2 containing the full number. The 1099 or W-2 will not be used for proof of identity. Non-US Citizens not eligible for a
SSN must present proof of ineligibility from the Social Security Administration (SSA). W2 and 1099 must have been issued within 5
years.
My social security number verification I will present is: SS Card W2 1099 Proof of ineligibility from SSA
3. CONNECTICUT RESIDENCY: You must present two different pieces of mail or electronic mail from two different sources showing
your name and Connecticut residence address, dated within 90 days unless stated otherwise on document checklist.
My 1st proof of residency I will present is: , my 2nd is
4. LEGAL PRESENCE IN THE UNITED STATES: Non U.S Citizens only.
My proof of legal presence I will present is:
5. NAME CHANGE DOCUMENTS, if applicable: If there have been multiple name changes, you must provide documentation to
prove the continuity of the names.
My name change document(s) I will present is(are):
6. Current non-driver ID, if issued, which must be surrendered. Visit our website at ct.gov/dmv/exchange to verify if you qualify for an
Exchange.
7. A printout of this appointment confirmation page.
8. The completed R229 application, page 2.
Bring your glasses or contact lenses, if needed, for testing. If you fail the vision test you will not be able to proceed to the
knowledge test and will be required to reschedule.
If under 18, parent or legal guardian must accompany you with their identification to sign the parental consent
(Legal guardian must present certificate of legal guardianship from the court).
If parent or legal guardian is unable to come with you, you must present a notarized certificate of parental consent form (Form
2-D).This form can be found on our website http://ct.gov/dmv/form2d
Study the Connecticut Driver's Manual You will be required to reschedule, wait seven days and repay the test fee if you fail the test.
If you fail to comply with the above requirements you will not be allowed to test and must reschedule your appointment.
If you fail to appear at your scheduled time you will be required to reschedule and repay the test fee.
If you are unable to keep this appointment and reschedule within two days of your appointment date you will be required to repay
the test fee. If you cancel within two days of your appointment date you will not be eligible for a refund of the test fee.
APPOINTMENT DETAILS
PIN: B4XEKJ4A Fee Paid: Learner Permit $19.00
Date/Day/Time: 4/7/2021 Wednesday 6:15 PM-Terminal 2 Test Fee $40.00
Testing Location: 1625 Highland Ave., Cheshire, CT, 06410 Total
$59.00
Authorization Code: 00815P Payment Date: 2/8/2021
PIN: B4XEKJ4A 4/7/2021 Wednesday 6:15 PM 1625 Highland Ave., Cheshire, CT, 06410-Terminal 2 $59.00
DMV USE OUT OF STATE DRIVE ADD/REMOVE
NEW TRANSFER ONLY ENDORSEMENT/RESTRICTION EXCHANGE RETEST
ONLY
APPLICATION FOR A NON-COMMERCIAL
LEARNER PERMIT AND/OR DRIVER LICENSE STATE OF CONNECTICUT
R-229 REV. 6-2014 DEPARTMENT OF MOTOR VEHICLES
On The Web At ct.gov/dmv
INSTRUCTIONS: Complete 1-18, 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
NO FEE LEARNER PERMIT NUMBER DATE OF ISSUE
(if not accompanied by authorized individual)
3. Applicable Fees US MILITARY
1. APPLICANT'S NAME (Last, First, Middle, Suffix) 2. GENDER 3. DATE OF BIRTH 4. HEIGHT 5. COLOR OF EYES
LIU, ALLEN M F 3/17/2005 ft. in.
6. MAILING ADDRESS (No., Street, City or Town, State, Zip Code) 7. RESIDENCE ADDRESS (If different from mailing address)
85 PECK HILL RD., WOODBRIDGE, CT, 06525
8. US CITIZEN? If "NO", list ALIEN REGISTRATION NO. 9. CONNECTICUT 10. DO YOU WANT TO BE IN THE ORGAN/TISSUE DONOR 11. 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. SOCIAL SECURITY NUMBER 13. LIST ANY OTHER NAMES EVER USED (Alias, Maiden, etc) 14. E-MAIL ADDRESS
770-38-1148
QUESTIONS YES ( ) NO ( )
15. Have you previously failed a driver's license FAILED LOCATION DATE
examination in Connecticut? VISION KNOWLEDGE ROAD
PERMIT, LICENSE OR ID NO. (9 digits) EXPIRATION DATE NO. OF YEARS
16. Do you now, or have you ever held a Connecticut Learner Permit,
License or Non-Driver Identification Card?
17. Do you now, or have you ever held an Operator's License or STATE DRIVER LICENSE OR ID. NO. EXPIRATION DATE NO. OF YEARS
Identification Card from another state?
IN WHAT STATE(S)?
18. 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 IDENTIFICATION SHOWN EXAMINERS INITIALS 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 APPLICANTS INITIALS CONFIRMING IDENTIFICATION
DOCUMENTS RETURNED
TEST COMPUTER/AUDIO WRITTEN WAIVED PASSED FAILED
ISSUE PERMIT WITH CORRECTIVE ISSUE DRIVE ONLY
PERMIT ISSUE LEARNER PERMIT ISSUE MOTORCYCLE PERMIT LENSES (B-RESTRICTION) (Y-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
SPECIAL EQUIPMENT
ROAD TEST WAIVED PASSED FAILED
AND LICENSE NON-COMMERCIAL CLASS ENDORSEMENT RESTRICTIONS (Circle All Applicable)
INFORMATION
D M Q B C D E F G R U Y
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. X
REAL ID DOCUMENT CHECKLIST Connecticut DMV
For Identity Verification
To obtain a new learner permit, driver license or ID card, or to obtain a verified driver license or ID card
you will need to provide valid/unexpired, original documents, or certified copies. Out of state learner
permits are not transferable.
Photocopies, notarized photocopies, non-certified copies, and damaged or mutilated
documents are not acceptable. DMV will scan and store images of all documents.
Two (2) forms of the same identification will not be accepted. If any document presented is in a language
other than English, it must be translated by a DMV approved translator. ct.gov/dmv/RealID
You must satisfy items 1 , 2 , 3 and if applicable 4 and 5 :
1 IDENTITY: SECONDARY document list
You must present two (2) forms of identification; at least £ Out of State US photo driver license
one of the documents must be from the Primary document £ US Territory or Canadian photo driver license
list. £ Out of State US or Canadian issued photo learner permit
£ Connecticut issued non-driver identification card, driver license
PRIMARY document list or learner permit
US born (Your driver license or ID may be required to be surrendered)
£ US or US Territory Birth Certificate or Registration of Birth £ US Military ID or dependent card with photo
(Hospital issued and Puerto Rico issued prior to July 1, 2010 £ Connecticut State Permit to Carry Pistols or Revolvers
not acceptable; foreign place of birth see Non-US Born) £ Military discharge/separation papers (DD-214)
£ US Passport or Passport Card £ Court Order: Must contain full name and date of birth (i.e. name
Non-US born change, adoption, marriage or civil union dissolution) Does not
£ US Passport or Passport Card include abstract of criminal or civil conviction
£ Foreign Passport w/ supporting documents (See £ Marriage or Civil Union Certificate (certified copy issued by
Legal Presence noted below)* town/city)
£ Certificate of Naturalization* £ Pilot’s license (issued by the US DOT Federal Aviation
£ Certificate of Citizenship* Administration)
£ Permanent Resident Card* £ Certified school transcript (school photo ID not acceptable)
£ US Consular Report of Birth Abroad £ Social Security Card (Not laminated or metal. 16 and older must
sign)
FULL LEGAL NAME £ CT Department of Corrections certificate (CN101503)
By law, the full name shown on the Primary document is your £ Baptismal certificate or similar document
legal name and will be printed on your card. If your name £ State or Federal Employee Identification with signature and
is different than the Primary document, see Name Change photo and/or physical description with or without date of birth
Documents section below. £ Employment Authorization card
£ Veteran Health Identification Card (VHIC)
* Subject to Verification using SAVE £ Federally Recognized Tribal Member ID card
(See 4. Legal Presence) £ DHS Trusted Traveler Cards (Global Entry, NEXUS, SENTRI,
FAST)
2 SOCIAL SECURITY NUMBER:
By law, you must present one of the following to prove your Non-US Citizens not eligible for a Social Security number must
Social Security number. The 1099 or W-2 must show your present proof of ineligibility from the Social Security Administration.
full Social Security number and is only for proof of Social
Security number, not identity.
£ Social Security card
£ W-2 form (issued within 5 years)
£ 1099 (issued within 5 years)
3 CONNECTICUT RESIDENCY:
You must provide two (2) different pieces of mail from two £ Medicaid or Medicare benefit statement
(2) different sources to prove your home is located in £ Current valid homeowner’s, renter’s policy or motor vehicle
Connecticut. The documents do not need to include a insurance card or policy dated within the previous 12 months
postmarked envelope and may have been sent to a P.O. Box £ Current valid Connecticut motor vehicle registration
or by email. Both documents must: £ Current motor vehicle loan statement for a motor vehicle
registered in your name
• Show your name and your Connecticut residence address £ Residential mortgage or similar loan contract, lease or rental
• Be dated within 90 days (unless stated otherwise below) contract showing signatures from all parties needed to execute
• Be computer generated (typed) the agreement and dated within the previous 12 months
£ Connecticut voter registration card
£ Postmarked mail (address may be handwritten) £ Change-of-address confirmation from the United States Postal
£ Bill from a bank or mortgage company, utility company, credit Service showing your prior and current address (Form CNL107)
card company, doctor or hospital £ Survey of your Connecticut property issued by a licensed
£ Bank statement or bank transaction receipt showing the surveyor
bank’s name and mailing address £ Official school records showing enrollment
£ Pre-printed pay stub showing your employer’s name and £ Parents or legal guardian of minor may provide any two of the
address foregoing documents addressed to the parent residing at same
£ Property or excise tax bill, or Social Security Administration address to prove minor residency, or use their own CT driver
or other pension or retirement annual benefits summary license or ID which shows the same address as one of the two
statement and dated within the previous 12 months required.
4 LEGAL PRESENCE IN THE UNITED STATES
(Non-US born): • Non-US Citizens not eligible for a Social Security number must
Legal status will be verified using Systematic Alien present proof of ineligibility from the Social Security
Verification of Eligibility (SAVE) which may take 10 business Administration and are not qualified for a verified driver license or
days or more. ID card.
£ US Passport or Passport Card • Only US Citizens and Permanent Residents are eligible for a
£ I-94 verified driver license or ID card.
£ I-551 Stamp in foreign passport
£ Permanent Resident card or Resident Alien card • B1/B2 visitor status is NOT eligible to obtain a CT credential.
£ Employment Authorization card
£ Refugee Travel document
£ F1 requires I-20 and I-94
£ J1 requires DS2019 and I-94
5 NAME CHANGE DOCUMENTS (if applicable): If there have been multiple name changes, you must provide
£ Marriage or civil union certificate (certified copy issued by documentation to prove the continuity of the names.
town/city)
£ Marriage or civil union dissolution NOTE: Your new name must verify with Social Security
£ Probate court name change document Administration (SSA). Visit the SSA first to change your name.
£ DHS Petition for Name Change (USCIS Form N-662) Allow at least 48 hours for SSA update.
If you have a question regarding acceptable documents, please phone the
DMV Contact Center 860-263-5700.
DI-3 REV. 8-2018
