APPLICATION FOR A LEARNER PERMIT B-307 REV. 1-2010 STATE OF CONNECTICUT DEPARTMENT OF MOTOR VEHICLES On The Web at ct.gov/dmv INSTRUCTIONS: Complete 1-13, then present items listed below to Cashier: 1. Identification (See reverse side of this form) 2. Resident Address Verification 3. Certificate of Parental Consent Form 2D (if not accompanied by authorized individual) 4. Test Fee, Learner Permit Fee 1. APPLICANT'S NAME (Last, First, Middle) VISION SCREENING RESULTS CERTIFICATION BY INSPECTOR/ AGENT KNOWLEDGE TEST CERTIFICATION BY APPLICANT PARENTAL CONSENT PROOF OF IDENTIFICATION 2. SEX 3. DATE OF BIRTH 4. HEIGHT 5. EYE COLOR M F 8. 6. MAILING ADDRESS (No., Street, City or Town, State, Zip Code) ft. in. 7. RESIDENCE ADDRESS (If different) 10. LIST ANY OTHER NAMES EVER USED (Alias, Maiden, etc.) 11. SOCIAL SECURITY NUMBER MEDICAL CERTIFICATION QUESTIONS YES NO DO NOT WRITE BELOW THIS LINE - OFFICE USE ONLY I hereby certify that I do not have any health or vision problems or conditions that prevent me from driving safely. Is your privilege to operate a motor vehicle suspended or subject to suspension in Connecticut or in any other state? SUSPENSION OCCURRED IN WHAT STATE? REASON FOR SUSPENSION IF YES, IN WHAT YEAR(S)? LICENSE OR ID CARD NO. (9 digits) TYPE OF ACCEPTABLE I.D. SHOWN I hereby request that a learner's permit and/or license be issued to the minor (age 16-17) filing this application. RELATIONSHIP TO MINOR SIGNED (Authorized Consenter) CONSENTER'S LIC. NO. OR OTHER I.D. X BRANCH OFFICE DATE SIGNED SIGNATURE OF APPLICANT X DATE SIGNED VISUAL AID USED NONE GLASSES/CONTACTS PASS FAIL RESULTS TYPE OF TEST TEST NUMBER COMPUTER WRITTEN ORAL TEST RESULT PASSED FAILED SIGNED (Inspector/Agent) X I hereby certify that the applicant has signed this application in my presence, and that I have examined the applicant and the results stated herein are true and correct. Learner's Permit With Corrective Lenses (B-restriction) US CITIZEN? 9. CONNECTICUT RESIDENT? YES NO YES NO 8a. If "NO", list ALIEN REGISTRATION NO. 13. The information provided to the Commissioner of Motor Vehicles herein is subscribed by me, the undersigned, under penalty of false statement, in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General 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. Do you now, or have you ever previously held a Connecticut license, CT Non-driver Identification card or a license or ID Card issued by another state? 12. ID SCANNED EXAMINER INITIALS STAMP NO.