DE-36 Driver License and ID Card Request form - International Center

MICHIGAN DEPARTMENT OF STATE DRIVER LICENSE AND ID CARD APPLICATION
Making a false statement on a driver license or ID card application can result in fines or criminal prosecution and action against your driving privilege.
Department personnel will notify law enforcement if they believe a fraudulent application is being made.
FULL LEGAL NAME (First) (Middle) (Last)
RESIDENCE ADDRESS (Required)
CITY
PHONE NUMBER
DATE OF BIRTH (Month/Day/Year)
PERMANENT MAILING ADDRESS (If different from residence)
COUNTY
ZIP CODE
CHECK ONE:
MALE
FEMALE
EYE COLOR HEIGHT (FT/IN) WEIGHT
WOULD YOU LIKE YOUR NAME ADDED TO THE ORGAN DONOR
REGISTRY?
IN THE LAST SIX MONTHS*, HAVE YOU HAD A FAINTING SPELL,
BLACKOUT, SEIZURE, OR OTHER LOSS OF CONSCIOUSNESS?
(*Twelve months if applying for a chauffeur or commercial driver license.)
IS YOUR DRIVER LICENSE CURRENTLY SUSPENDED, REVOKED,
CANCELLED OR DENIED IN MICHIGAN OR ANY OTHER STATE?
WILL YOU BE OPERATING A MOTORCYCLE ON PUBLIC ROADS?
IN THE LAST SIX MONTHS*, HAVE YOU HAD A MEDICAL
CONDITION WHICH AFFECTED YOUR ABILITY TO DRIVE?
(*Twelve months if applying for a chauffeur or commercial driver license.)
ARE YOU A CITIZEN OF THE UNITED STATES?
ARE YOU A RESIDENT OF THE STATE OF MICHIGAN?
MAILING ADDRESS CITY STATE ZIP CODE
I certify under the penalty for perjury that I am a legal Michigan resident, the statements made on this application are true, and that a court is not holding my license.
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
X SIGNATURE OF APPLICANT
DATE (Month/Day/Year)
APPLICATION TYPE (Circle one) LICENSE TYPE GROUP DESIGNATION ENDORSEMENTS
TIP ORIG. REN. DUP. CORR. VAL. O C M GDL 1 GDL 2 GDL 3 PID A B C CY F H N P R S T SEAS.
CORRECTIVE LENS? CDL RESTRICTIONS SAVE CASE NUMBER SOCIAL SECURITY DOCUMENT PRESENTED
YES NO 28 29 30
LEGAL PRESENCE DOCUMENT PRESENTED
U.S. BIRTH CERTIFICATE
STATE COUNTY FILE #
(original or certified copy)
U.S. PASSPORT OR PASSPORT CARD
COUNTRY EXP. DATE FILE #
(valid, unexpired)
ARRIVAL AND DEPARTURE FORM
ISSUE DATE EXP. DATE FILE #
(I-94)
U.S. VISA
TYPE (F-1, J-1 etc.) EXP. DATE FILE #
(immigrant or non-immigrant)
PERMANENT RESIDENT CARD (I-551)
ISSUE DATE EXP. DATE FILE #
(valid, unexpired)
EMPLOYMENT AUTHORIZATION CARD
ISSUE DATE EXP. DATE FILE #
(EAD)
CERTIFICATE OF CITIZENSHIP
ISSUE DATE FILE #
(N-560, N-561)
CERTIFICATE OF NATURALIZATION
ISSUE DATE FILE #
(N-550, N-570, N-578)
CONSULAR REPORT OF BIRTH ABROAD
ISSUE DATE FILE #
(FS-240, DS-1350, FS-545)
IDENTITY DOCUMENT PRESENTED
U.S./CANADIAN DRIVER LICENSE or PID
STATE DL/PID # FILE #
(valid or expired less than 1 year)
FOREIGN PASSPORT
COUNTRY EXP. DATE FILE #
(valid or expired less than 1 year)
U.S. MILITARY ID CARD (DD-2, DD1173, CAC card)
ISSUE DATE EXP. DATE FILE #
(valid or expired less than 1 year)
U.S. LEGAL DOCUMENTS
STATE TYPE FILE #
(marriage, divorce, adoption, legal name change)
PHOTO ID CARD
ISSUE DATE EXP. DATE FILE #
(issued by federal or Michigan or tribal government agency)
U.S. SCHOOL RECORDS
ID TYPE SCHOOL CITY, STATE, TELEPHONE #
(photo, diploma, transcript, yearbooks)
MDOC PRISONER ID CARD
FILE #
(requires verification)
OTHER TYPE FILE #
RESIDENCY DOCUMENTS PRESENTED (at least two documents required)
RESIDENCY DOCUMENTS
TYPE
TYPE
EMPLOYEE SIGNATURE
X
MANAGER OR DESIGNEE SIGNATURE
X
BRANCH NUMBER
ADDITIONAL
Refer App? (Circle one) C E R O F
INFORMATION
CDL ENFORCE RESEARCH OTHER FOREIGN ADDRESS Request for exception? YES NO
DOCUMENTS IN POSSESSION OF? Applicant Mailed In-House TRANSACTION #S, INCLUDING VOIDS
Branch
COMMENTS – BE SPECIFIC (Use additional pages if necessary) – If referring application or adding comments, print name, sign, and date at bottom.
DE-36 (10/12)
Authority granted under Public Act 300 of 1949, as amended.

WRITTEN/ORAL TEST RESULTS
CDL WRITTEN/ORAL TEST RESULTS
General Knowledge
Air Brakes
Enter Date and Pass or Fail Test Score
Enter Test # for Chauffeur, Moped, Motorcycle,
____/____/____ P______ F______ ____/____/____ P______ F______
and Recreational Double tests.
____/____/____ P______ F______ ____/____/____ P______ F______
Operator Audio Test Audio Test
_____/_____/_____ P______ F______ ____/____/____ P______ F______ ____/____/____ P______ F______
_____/_____/_____ P______ F______ ____/____/____ P______ F______ ____/____/____ P______ F______
Audio Test Combination Vehicle Passenger
_____/_____/_____ P______ F______ ____/____/____ P______ F______ ____/____/____ P______ F______
_____/_____/_____ P______ F______ ____/____/____ P______ F______ ____/____/____ P______ F______
Road Sign Test Audio Test Audio Test
_____/_____/_____ P______ F______ ____/____/____ P______ F______ ____/____/____ P______ F______
_____/_____/_____ P______ F______ ____/____/____ P______ F______ ____/____/____ P______ F______
Moped Double Trailers School Bus
#______ _____/_____/_____ P____ F____ ____/____/____ P______ F______ ____/____/____ P______ F______
#______ _____/_____/_____ P____ F____ ____/____/____ P______ F______ ____/____/____ P______ F______
Motorcycle Audio Test Audio Test
#______ _____/_____/_____ P____ F____ ____/____/____ P______ F______ ____/____/____ P______ F______
#______ _____/_____/_____ P____ F____ ____/____/____ P______ F______ ____/____/____ P______ F______
Recreational Double
Tanker
#______ _____/_____/_____ P____ F____ ____/____/____ P______ F______
#______ _____/_____/_____ P____ F____ ____/____/____ P______ F______
Chauffeur
Audio Test
#______ _____/_____/_____ P____ F____ ____/____/____ P______ F______
#______ _____/_____/_____ P____ F____ ____/____/____ P______ F______
Minor Restricted License
Hazardous Materials (No Oral Test or Foreign Language Test Allowed)
Segment 1 School # ______ Issued ___/___/____
____/____/____ P_____ F_____ ____/____/____ P_____ F_____
DA Letter dated
____/____/____
If necessary, attach an additional DE-36 to record more test scores.
____/____/____ P_____ F_____ ____/____/____ P_____ F_____
DE-36 (10/12)
Authority granted under Public Act 300 of 1949, as amended.