Application for State of Maine Identification Card
(Please Print Clearly) |
FEE $5.00 |
To obtain an identification card you must provide proof of legal presence in the United States and
documentation of Maine residency.
Name: ________________________________________________________________________________________________________________
FirstMiddleLast
Mailing Address: ______________________________________________________________________________________________________
Physical Residence: ___________________________________________________________________________________________________
Date of Birth: ____/____/____ Sex: |
Male Female |
Social Security Number: __________________________________ |
Height: ________Ft. ________In. |
Weight: ________ lbs. |
Hair Color: _____________ Eye Color: _____________ |
Telephone Number: _______________________
If you wish to be an organ and tissue donor, check box to consent to organ and tissue donation.
By checking “yes” above, you are consenting to organ and tissue donation. Your consent to be an organ and tissue donor will then be clearly indicated on the front of your identification card with a small red heart. For additional information on organ and tissue donation, you may contact the Maine Transplant Program (207-871- 2000), the National Kidney Foundation of Maine (207-772-7270) or New England Donor Bank (1-800-446- 6362) or visit our website at www.maine.gov/sos/bmv/organ.htm It is important to discuss your decision with your family.
Social Security Number Disclosure Statement
This statement is made in accordance with the Federal Privacy Act of 1974, Section 7(b). Disclosure of your social security number is required by 29-A MRSA §1301(5) and (6) to apply for or renew a driver’s license or
non-driver identification card. Your social security number will be used solely for identification purposes and will be kept confidential.
“I understand that knowingly supplying false information on this form is a Class D crime under Title 17-A, punishable by confinement of up to 364 days or monetary fine of up to $2000.00 or both”
__________________________________________________________________________ |
_____________________________________ |
Signature in ink |
Date |
See reverse for acceptable identification documents
MV-16 Rev 07/2011
Two (2) of the following documents are required for identification
One must indicate your date of birth and the other must bear your written signature. If you are the holder of a driver’s license from any state or province, that license must also be produced. Photocopies
are not accepted.
____ Adoption Record |
____ Draft Card |
____ Parent/Guardian** |
____ Baptismal Record |
____ Driver’s License |
____ Passport |
____ Birth Certificate |
____ Driver’s Permit |
____ Permanent Resident Card |
____ Certificate of Marriage |
____ Employment Authorization Card |
____ Resident Alien Card |
____ Citizenship Document |
____ Machine Readable Visa |
____ School Record/Transcript |
|
|
(Certified) |
____ Concealed Weapon Permit |
____ Medical Record/Hospital Record |
____ Social Security Card |
____ Copy of Marital Application |
____ Military Dependent I.D. Card |
|
____ Court Document |
____ Military Discharge (DD-214) |
|
____ Divorce Papers |
____ Military I.D. Card |
|
**Parent or Guardian must appear in person and prove identity. This option applies only to minors.
NOTE: In addition to an original birth certificate, a certified copy of a birth certificate is acceptable. A document is certified if it has an embossed seal or stamp of the issuing agency. A photocopy of a certified copy of a birth certificate or an original birth certificate is NOT acceptable.
_________________________________________________________________
Issuing Official
Bureau of Motor Vehicles License Information
101 Hospital Street, 29 State House Station, Augusta, ME 04333-0029
207 624-9000 Extension 52114 |
TTY Users call Maine relay 711 |