Operators License "*" indicates required fields Did you already fill out the form in the Town office?* YES NO Name* First Last Phone*Email* Date of Birth* Month Day Year Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number*Drivers License Number*Current and Previous Employment (Last two years)Employer Name & City / StateEmployer Name & City / StateEmployer Name & City / StateList Previous Addresses for Last 3 Years (If different from current address)Do you have Traffic Citations? / Arrests? / Convictions from the last two years?* Yes No Please Explain. You will be rejected if you do not disclose ALL*Are you a convicted felon?* Yes No Do you have any PENDING criminal charges?* Yes No Name of local business you will be working at*Original or Renewal License* Original - $50.00 Renewal - $50.00 Do you also need a Provisional License?* Yes No Online Transaction Fee* Price: $0.00 Total Credit CardCard Details Cardholder Name Δ
