STATE OF CONNECTICUT

DEPARTMENT OF MOTOR VEHICLES

ct.gov/dmv
We'd like to hear from you!
Date:

CONGRATULATIONS

4/12/2015

DRIVE-ONLY

GERSON GUTENBERG SOARES REGIS

YOU HAVE SUCCESSFULLY SCHEDULED YOUR LEARNER PERMIT VISION AND KNOWLEDGE TEST APPOINTMENT

ALL DOCUMENTS PRESENTED TO THE DMV MUST BE ORIGINAL OR CERTIFIED COPIES.

PHOTOCOPIES WILL NOT BE ACCEPTED.

BE PREPARED. Bring the following REQUIRED documents with you!

Please refer to the DRIVE ONLY document checklist on page 3 or at ct.gov/dmv/driveonly for a complete list of acceptable
documents to answer 1-3 below.
1.

IDENTITY: You must present two forms of identification. At least one of the documents must be from the primary document list.
My primary document I will present is:

2.

, my 2nd is

CONNECTICUT RESIDENCY: You must present two different pieces of mail or electronic mail from two different sources. Mail
must show your name and Connecticut residence address, be dated 90 days or older, but not more than two years old; unless stated
otherwise on document checklist.
My 1st proof of residency I will present is:

3.

, my 2nd is

NAME CHANGE DOCUMENTS, if applicable: If there have been multiple name changes, you must provide documentation to
prove the continuity of the names.
My name change document(s) I will present is (are):

4.

A printout of this appointment confirmation page.

5.

The completed R229 application, page 2.

Bring your glasses or contact lenses, if needed, for testing. If you fail the vision test you will not be able to proceed to
the knowledge test and will be required to reschedule.
If under 18, parent or legal guardian must accompany you with their identification to sign the parental consent
(Legal guardian must present certificate of legal guardianship from the court).
If parent or legal guardian is unable to come with you, you must present a notarized certificate of parental consent form (Form
2-D).This form can be found on our website http://ct.gov/dmv/form2d
Study the Connecticut Driver's Manual You will be required to reschedule, wait seven days and repay the test fee if you fail the
test.
If you fail to comply with the above requirements you will not be allowed to test and must reschedule your appointment.
If you fail to appear at your scheduled time you will be required to reschedule and repay the test fee.
If you are unable to keep this appointment and are rescheduling within two days of your appointment date you will be required to
repay the test fee. If you are canceling within two days of your appointment date you will not be eligible for a refund of the test fee.

APPOINTMENT DETAILS
PIN CODE:

YUNY7LVD

Date/Day/Time:

Learner Permit:

$19.00

9/11/2015 Friday 9:30 AM-Terminal 1

Test Fee:

$40.00

Testing Location:

1625 Highland Ave., Cheshire, CT, 06410

Total:

Authorization Code:

150465

$59.00

Fee:

Payment Date:

4/12/2015

PIN: YUNY7LVD
DMV USE
ONLY

NEW

9/11/2015 Friday 9:30 AM 1625 Highland Ave., Cheshire, CT, 06410-Terminal 1 $59.00
OUT OF STATE
TRANSFER

ADD/REMOVE
ENDORSEMENT/RESTRICTION

DRIVE
ONLY

APPLICATION FOR A NON-COMMERCIAL

LEARNER PERMIT AND/OR DRIVER LICENSE
R-229 REV. 6-2014

EXCHANGE

RETEST

STATE OF CONNECTICUT

DEPARTMENT OF MOTOR VEHICLES

On The Web At ct.gov/dmv

DRIVE-ONLY

INSTRUCTIONS: Complete 1-18, then present

1. Required Identification Documents & Proof of Connecticut
Residency: see "Acceptable Forms of ID" at ct.gov/dmv
2. 16 and 17 year olds: Certificate of Parental Consent Form 2D
(if not accompanied by authorized individual)
3. Applicable Fees

LEARNER PERMIT NUMBER

NO FEE

DATE OF ISSUE

US MILITARY

1. APPLICANT'S NAME (Last, First, Middle, Suffix)

6. MAILING ADDRESS (No., Street, City or Town, State, Zip Code)

4. HEIGHT

3. DATE OF BIRTH

2. GENDER

REGIS, GERSON, GUTENBERG SOARES

4/26/1981

ft.

5. COLOR OF EYES
in.

7. RESIDENCE ADDRESS (If different from mailing address)

65 / 12 WESTE ST, DAMBURY, CT, 06810

8.

US CITIZEN?
Yes

11. DAYTIME PHONE NO.

10. DO YOU WANT TO BE IN THE ORGAN/TISSUE DONOR
REGISTRY?
If yes, you are agreeing to be a donor
and the designation will be on your
Yes
No
Yes
No
(
)
license.
13. LIST ANY OTHER NAMES EVER USED (Alias, Maiden, etc)
14. E-MAIL ADDRESS
9. CONNECTICUT
RESIDENT?

If "NO", list ALIEN REGISTRATION NO.

No

DRIVE ONLY

12. SOCIAL SECURITY NUMBER

QUESTIONS

YES ( ) NO ( )

15. Have you previously failed a driver's license

examination in Connecticut?

FAILED

16. Do you now, or have you ever held a Connecticut Learner Permit,
License or Non-Driver Identification Card?

PERMIT, LICENSE OR ID NO. (9 digits)

17. Do you now, or have you ever held an Operator's License or

Identification Card from another state?

STATE

CERTIFICATION
BY APPLICANT

DATE

ROAD

KNOWLEDGE

NO. OF YEARS

EXPIRATION DATE

DRIVER LICENSE OR ID. NO.

EXPIRATION DATE

NO. OF YEARS

IN WHAT STATE(S)?

18. Is your privilege to operate a motor vehicle suspended or subject to

suspension in Connecticut or in any other state?

SELECTIVE
SERVICE
CONSENT

LOCATION

VISION

Section 14-36l of the Connecticut General Statutes requires the Commissioner to transmit my
information to the Selective Service System. By signing and submitting this application, I consent
to be registered with the Selective Service System, provided I am at least age 16 but under age
MEDICAL
26 and meet the criteria for registration in accordance with the Military Selective Service Act. If I
CERTIFICATION
am under age 18, I understand that my information will be transmitted to Selective Service but I
will not be registered until I reach age 18.
The information provided to the Commissioner of Motor Vehicles herein is SIGNATURE OF APPLICANT
subscribed by me, under penalty of false statement, in accordance with
the provisions of Section 14-110 and 53a-157b of the Connecticut General
Statutes. I understand that if I make a statement which I do not believe to
be true, with the intent to mislead the Commissioner, I will be subject to
X
prosecution under the above-cited laws.

I hereby certify that I do not

have any health or vision
problems or conditions that
prevent me from driving safely.
DATE SIGNED

DO NOT WRITE BELOW THIS LINE - OFFICE USE ONLY

PROOF OF
IDENTIFICATION
FULL LEGAL
NAME
PARENTAL
CONSENT
AGE 16 OR 17 ONLY

VISION
SCREENING
RESULTS
KNOWLEDGE
TEST
PERMIT
AGENT
CERTIFICATION
DRIVER
TRAINING

HOME
TRAINING/
COMMERCIAL
TRAINING
CERTIFICATION

TYPE OF IDENTIFICATION SHOWN

EXAMINERS INITIALS

STAMP NO.

I.D. SCANNED FIRST VISIT

If different than entered in name section above (# 1)

I hereby request that a learner's permit RELATIONSHIP TO MINOR

and/or license be issued to the minor
filing this application.
VISUAL AID USED

NONE

SIGNED (Authorized Consenter)

X
AGENTS INITIALS

RESULTS

GLASSES/CONTACTS

PASSED

WRITTEN

WAIVED

PASSED

FAILED

I hereby certify that I have examined the applicant's identity

documents and the test results stated herein are true and
correct.
SCHOOL NAME
CLASSROOM

APPLICANTS INITIALS CONFIRMING IDENTIFICATION

DOCUMENTS RETURNED

ISSUE PERMIT WITH CORRECTIVE

LENSES (B-RESTRICTION)

ISSUE MOTORCYCLE PERMIT

ISSUE LEARNER PERMIT

PUNCH NO. AND PUNCH

FAILED

TEST RESULTS

COMPUTER/AUDIO

CONSENTER'S LIC. NO. OR OTHER I.D.

SIGNED (Agent)

PUNCH NO. AND PUNCH

ISSUE DRIVE ONLY

(Y-RESTRICTION)
DATE SIGNED

X
COMMERCIAL SCHOOL LICENSE NO.

DRIVER EDUCATION CERTIFICATE NO.

SCHOOL NAME (If same as above print "same") COMMERCIAL SCHOOL LICENSE NO.

DRIVER EDUCATION CERTIFICATE NO.

INSTRUCTION
PRACTICE
DRIVING

I hereby subscribe and certify under penalty of false statement, in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes that I
understand that if I make a statement, which I do not believe to be true, with the intent to mislead the Commissioner I will be subject to prosecution under the above-cited laws, that,
I am qualified under Section 14-36, of the Connecticut General Statutes, over 20 years of age, have no suspensions within the previous 4 years and the Applicant has received the
required training, including the equivalent of 22 hours classroom training; 40 hours on-the-road instruction; the 8 hours Safe Driver course, including a 2 hour Parent Training, as
supported by a parent log and/or driving school certificate.
OPERATOR LICENSE NUMBER OR
SIGNATURE OF INSTRUCTOR (Home Training/Commercial)
1
2
3
SCHOOL LICENSE NUMBER
Comm/Sec Only
Home Training
Comm/Sec and Home
30 hrs class/minimum
30 hrs class
22 hr class equiv
40 hr on-the-road
8 hr safe driving plus home 40 hrs on-the-road
8 hr safe driving
training 40 hrs on-the-road
X
SPECIAL EQUIPMENT

ROAD TEST
AND LICENSE
INFORMATION
AGENT
CERTIFICATION

WAIVED

PASSED

NON-COMMERCIAL CLASS

FAILED

ENDORSEMENT

RESTRICTIONS (Circle All Applicable)

I hereby certify that I have verified the applicant's SIGNED (Agent)

identity and the test results stated herein are true
X
and correct.

Y
PUNCH NO. AND PUNCH

DATE SIGNED

DRIVE ONLY DOCUMENT CHECKLIST

Connecticut DMV

To obtain a new learner permit or transfer your out of state driver license you must provide original or certified
documents. Out of state learner permits are not transferable.
Photocopies, notarized photocopies and non-certified copies are not acceptable. DMV will scan and store images
of all documents.
If any document is in a language other than English, it must be translated by a DMV approved translator. Visit
ct.gov/dmv/translators for list of DMV approved translators.
US Citizens and documented immigrants and non-immigrants (including B1 and B2 visitors) are NOT eligible for a
Drive Only credential.

ct.gov/dmv/driveonly

You must schedule an appointment online at ct.gov/dmv/qsc.

IDENTITY:
You must present two (2) forms of identification; at least one document must be from the Primary document list.
PRIMARY document list
Foreign Passport (not expired for more than 3 years)
Valid, unexpired consular identification document issued by your country of citizenship
Non-US Consular report of your birth in a foreign country
SECONDARY document list
Valid, unexpired motor vehicle operator's license, with security features, issued by another state or country
Valid foreign voter registration card
Marriage certificate issued by any state or territory of the United States
Certified school transcript
Baptismal certificate or any similar document
AND
CONNECTICUT RESIDENCY:
Two (2) different pieces of mail from two (2) different sources to prove your home is located in Connecticut. Mail must include your name and address and be
dated in accordance with the list below as of the date you submit an application for a Connecticut permit or driver license.
Parents or legal guardian of minor may provide any two of the foregoing documents addressed to the parent residing at same address to prove minor residency,
or use their own CT driver license or ID which shows the same address as one of the two required.
The two proofs of residency can be from either list.
New Learner Permits and Out of State transfers - Mail must be older than 90 days from (A) or older than 12 months from (B). Cannot be older than two (2)
years.
Renewals - Mail must be within 90 days from (A) or within 12 months from (B).

A bill from a bank or mortgage company, utility company, credit card

company, doctor or hospital
A bank statement or bank transaction receipt showing the bank's name
and mailing address
A preprinted pay stub
A Medicaid or Medicare benefit statement
Any postmarked mail
A change of address confirmation from the United States Postal
Service indicating an applicant's current and prior address
A survey of an applicant's real property issued by a licensed surveyor
Any official school records showing enrollment

A property or excise tax bill

An annual benefits summary statement from the Social Security
Administration or other pension or retirement plan
A current homeowner's insurance or renter's insurance policy or motor
vehicle insurance card or policy
A residential mortgage or similar loan contract, lease or rental contract
showing signatures from all parties needed to execute the agreement

AND
NAME CHANGE DOCUMENTS (if applicable):
Marriage or civil union certificate (certified copy issued by town/city)
Marriage or civil union dissolution
Probate court name change document
If there have been multiple name changes, you must provide documentation to prove the continuity of the names.
When you schedule an appointment online, you will sign an affidavit that you will file an application to legalize your immigration status when you are eligible.
The Connecticut DMV will check your criminal history. If you have a Connecticut felony, you will not be eligible for a Drive Only credential or a refund of any fees
collected.

If you have a question regarding acceptable documents, please phone the DMV Call Center 860.263.5700
DI-4 New 9-2014