NewYork State Department of MotorVehicles
DRIVER HISTORY DISCLOSURE
Client ID:__________________________ |
Name: __________________________________________________ |
Date of Birth: |
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Sex: ______ |
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1) Have you ever applied for or been issued a driver license in NewYork State or elsewhere in any other name? |
YES |
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NO |
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IfYes, please print the other name(s) in full: |
2)Please list all places in which you have ever been issued a driver license. Include all U.S. states (including NY), territories and possessions; the District of Columbia; and Canadian provinces or territories.
3)Have you had any alcohol/drugged driving convictions in your lifetime?
YES NO
a.IfYes, indicate how many in: NewYork
Other than NewYork
b.Indicate the non-NewYork state(s) or other location(s) and the year in which those alcohol/drugged driving conviction(s) occurred.
STATE (or other location) |
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YEAR |
STATE (or other location) |
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YEAR |
STATE (or other location) |
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YEAR |
STATE (or other location) |
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YEAR |
STATE (or other location) |
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YEAR |
CERTIFICATION: I certify that the information I have given on this form is true. I understand that the NYS DMV may contact the jurisdictions indicated to validate the information provided.
IMPORTANT: Making a false statement on this disclosure, or in any proof or statement in connection with it, or deceiving or substituting, or causing another person to deceive or substitute in connection with this disclosure, may subject you to criminal prosecution for a misdemeanor or felony under theVehicle &Traffic Law and/or Penal Law.
Signature:Date:
Office Use Only:
Office:
TransactionType:
MV-47 (3/13) |
www.dmv.ny.gov |