BMV FORM NO. (2019-12) – REV. Jan. 21-2020 
 
(PRINT) FIRST NAME                                                  MIDDLE NAME                                                        LAST NAME 
 
 
RESIDENCE ADDRESS 
STREET: 
 
CITY:                                                              ZIP: 
MAILING ADDRESS 
ADDRESS: 
 
CITY:                                                                  ZIP: 
BIRTH DATE  
 
_______ ________ ________ 
SOCIAL SECURITY NUMBER  
 
_________      _________     __________   
EMAIL ADDR.: 
 
PHONE #:   
SEX 
BLOOD TYPE 
ORGAN DONOR  
 
   YES               NO 
GLASSES 
 
  YES           NO 
HEIGHT 
 
 
_____FT _____IN 
WEIGHT
 
 
__________ LBS 
EYE COLOR:
 
HAIR COLOR: 
  
PLACE OF BIRTH
 
MILLITARY DRAFT REGISTRATION  
 
“BY SUBMITTING THIS APPLICATION, I AM CONSENTING TO REGISTRATION WITH THE SELECTIVE SERVICE SYSTEM, IF SO REQUIRED BY FEDERAL LAW. IF UNDER (18) YEARS OF AGE, I 
UNDERSTAND THAT I WILL BE REGISTERED AS REQUIRED BY FEDERAL LAW WHEN I ATTAIN EIGHTEEN (18) YEARS OF AGE. “ 
 
WARNING  
 
UNDER TITLE 20, SECTION 548 VIC, IT IS IN VIOLATION “TO USE FALSE OR FICTITIOUS NAMES IN ANY APPLICATION FOR A DRIVER’S LICENSE OR IDENTIFICATION CARD, OR KNOWINGLY 
TO MAKE A FALSE STATEMENT, KNOWINGLY CONCEAL A MATERIAL FACT OR OTHERWISE COMMIT A FRAUD IN ANY SUCH APPLICATION.” 
 
 
_____________________________________________                                       _____________________ 
                                   Signature                                                                                                  Date  
 
No appointment will be given by phone. Cancellation must be made within 48 hours prior to the test date by phone or in 
person. If test is not canceled, payment will be required for a new appointment. 
Please bring your own vehicle (NO RENTAL) proceed to the BMV with a driver who has a valid V.I. Driver’s License. 
Emergency brake must be in the center of the vehicle. 
TO CANCEL CALL 340-713-4268 WITHIN 48 HOURS 
 
For BMV Office Use ONLY. 
Receipt Number Appointment 
Date 
Time 
Authorized 
Date 
Written Test / 
Road Test 
 
 
 
 
 
Written Test / 
Road Test 
 
 
 
 
 
Written Test / 
Road Test 
 
 
 
 
 
Written Test / 
Road Test 
 
 
 
 
 
 
GOVERNMENT OF THE VIRGIN ISLANDS  
OF THE UNITED STATES OFFICE OF THE GOVERNOR  
BUREAU OF MOTOR VEHICLES  
 
APPLICATION FOR FIRST TIME VI DRIVER’S LICENSE MEDICAL FORM  
INFORMATION ON THE BACK TO BE FILLED OUT BY A LICENSED PHYSICIAN
SIGN
 
BMV FORM NO. (2019-12) – REV. Jan. 21-2020 
 
INFORMATION TO BE FILLED OUT AND SIGNED BY A LICENSED PHYSICIAN