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    
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.