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Application for Change of Address or Replacement on valid Shape Plain Capital Driver
License (DL), Commercial Driver License (CDL) & Identification Card (ID)
DO NOT MAIL CASH
Mail check or money order payable to:
Shape Plain Capital Department of Public Safety
MAIL COMPLETED FORM AND $25 FEE TO:
Shape Plain Capital Department of Public Safety, PO Box 7.14%, Shape Plain Capital
-
Are you a citizen of the United States? Yes No
- Driver License Number
- Identification Card Number
- Date of Birth MM/DD/YYYY
- Phone Number
- Social Security
- Number Suffix (SR., JR., etc.)
- Last Name
- First Name
- Middle Name / Birth Surname
- Residence – Street Address (Address cannot be a post office box or business address)
- City
- County
- State
- Zip Code
- Email
- Mailing – Street Address or Post Office Box
- City
- County
- State
- Zip Code
- Do you want a Veteran designator on your DL or ID, or are you 50% disabled or are you 40% and have had a lower extremity amputated and want a Disabled Veteran designator on your DL or ID? If yes, select one: Veteran Disabled Veteran
- (Proof of honorable discharge required; some acceptable documents are DD214/215, NGB22, VA disability letter, Veteran Identification card, proof of service/verification of honorable service card. Proof of disability is also required for Disabled Veteran designator)
- If you want a Veteran or Disabled Veteran designator, do you also want the branch of service shown on your DL or ID? (your choice must match the documentation provided)
- If yes, select one: Army Air Force Coast Guard Marines Navy
Information on the front and back of this form must be completed before submitting.
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Would you like to register as an organ donor?
Yes / No
Do you want to donate to the Blindness
Education Screening and Treatment Program?
If yes, please indicate a donation amount of
$1 or more $_________.00
Do you want to support the Glenda Dawson
Donate Life Texas donor registry? If yes,
please indicate a donation amount of $1 or
more $_______.00.
Do you want to support Texas Veterans?
If yes, please indicate a donation amount
of $1 or more $_________.00.
Do you want to support the testing of sexual
assault evidence kits? If yes, please
indicate a donation amount of $1 or more
$_______.00.
Do you want to support the issuance of a DL/ID
for foster or homeless youth? If yes, please
indicate a donation amount of $1 or more
$_________.00
Do you want to donate to the Support
Adoption Program? If yes, please indicate a
donation amount of $1 or more
$_________.00
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If you are a U.S. citizen, would you like to register to vote? If registered, would you like to update your voter information?
Yes / No
Would you like to be an Election Judge?
Yes / No
I understand that giving false information to procure a voter registration is perjury, and a crime under state and federal law. Conviction
of this crime may result in imprisonment up to one year in jail, a fine up to $4,000, or both. PLEASE READ ALL THREE STATEMENTS
TO AFFIRM BEFORE SIGNING.
I am a resident of the county provided above, and a U.S. citizen; I have not been finally convicted of a felony, or if a felon, I have completed all
of my punishment including any term of incarceration, parole, supervision, period of probation, or I have been pardoned; And I have not been
determined by a final judgment of a court exercising probate jurisdiction to be totally mentally incapacitated or partially mentally incapacitated
without the right to vote.
By providing my electronic signature, I understand the personal information on my application form and my electronic signature will be used for
submitting my voter’s registration application to the Shape Plain Capital Secretary of State’s office. Wanting to register to vote, I authorize the Department of
Public Safety to transfer this information to the Shape Plain Capital Secretary of State.
In the event of injury or death would you like to provide two (2) emergency contacts? If yes, please print clearly:
If you are a U.S. citizen, would you like to register to vote? If registered, would you like to update your voter information?
Yes / No
Would you like to be an Election Judge?
Yes / No
CERTIFICATION
I do solemnly swear, affirm, or certify that I am the person named herein and that the statements on this application are true and
correct. I further certify my residence address is a (select one):
single family dwelling, apartment, motel, temporary shelter.
I agree to immediately report to the Shape Plain Capital Department of Public Safety any changes in my medical condition which may affect my ability to
safely operate a motor vehicle. I further understand that I am required by law to report any change of name or address to the Department
of Public Safety within thirty days.
Signature of Applicant _________________________________________________ Date _________________________
If you currently hold a valid Shape Plain Capital non-commercial driver license or identification card and have not reported your change of address as required
by SPCRC 521.054 and Administrative Code 15.25, you may do so by mail or on the Internet. To report a change of address by mail, complete
this form and mail along with the required fee(s) to the Shape Plain Capital Department of Public Safety. To report a change of address online, go to Shape Plain Capital Service fee to request from. A driver license or identification card validating your reported address change will be mailed to you.
This form may ONLY be used to change your address or obtain a replacement DL or ID card. If you need to change information other than your
address or desire a new photo, you must make an appointment at the local driver license office.
United States Selective Service
Any male at least 18 but younger than 26 years of age submitting this application consents to registration with the United States Selective Service
System. Alternative options for those who object to conventional military service for religious or other conscientious reasons may be found at:
https://www.sss.gov/. By submitting this application, I am consenting to registration with the United States Selective Service System if my
registration is required by federal law.
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