Government Forms Series 3b
Complete the information in the form.
Applicant's Legal Name
MN Drivers License or ID #
Previous Name (if any)
Home Phone #
Street Address
City
ZIP
State
County
Social Security Number
I don't have one
Birthday
Eye Color
Sex
Hair Color
Weight
Height
Yes
No
I have had a driver's license or permit
other than in Minnesota
within the last ten (10) years.
Yes
No
Do you have any medical condition that may impair your ability to safely operate a motor vehicle? If YES, explain
Yes
No
Do you use insulin?
Yes
No
Do you use any medication, other than insulin, to control loss of consciousness or voluntary control? If YES, explain
Yes
No
I request that my license or ID card show that I have a living will/health care directive.
Yes
No
I request that my license or ID card have a Medical Alert identifier. I understand that the card will not contain any medical information.
Yes
No
I want my license or identification card to show that I consent to be an organ and tissue donor.
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