DL-14A Applicant Form

Adult form. Save draft any time. Use “Save + Print” when you want the filled PDF generated for signature.

Application Basics
Applicant Information
Contact Information
Emergency Contacts

In the event of injury or death, you may provide up to two emergency contacts.

Alternate Address
Required Information From All Applicants
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 registration application to the Texas Secretary of State’s office. Wanting to register to vote, I authorize the Department of Public Safety to transfer this information to the Texas Secretary of State.
Proof of disability required.
Proof of honorable discharge required; some acceptable documents are DD214/215, NGB22, VA disability letter, Veteran Identification card, or proof of service / verification of honorable service card. Proof of disability is required for Disabled Veteran designator.
Physician must complete form DL-101.
Yes = Add/Keep my name on the Donate Life Texas Registry (Add/Keep Hero’s Heart Symbol).
No = Does not add your name to the Registry and does not remove your name if already registered.
By selecting no, you must remove your name from the Donate Life Texas registry separately.
If yes, please indicate a donation amount of $1 or more.
If yes, please indicate a donation amount of $1 or more.
If yes, please indicate a donation amount of $1 or more.
If yes, please indicate a donation amount of $1 or more.
If yes, please indicate a donation amount of $1 or more.
If yes, please indicate a donation amount of $1 or more.
Medical History
Examples, including but not limited to: diagnosis or treatment for heart trouble, stroke, hemorrhage or clots, high blood pressure, emphysema (within the past two years), progressive eye disorder or injury (i.e., glaucoma, macular degeneration, etc.), loss of normal use of hand, arm, foot or leg, blackouts, seizures, loss of consciousness or body control (within the past two years), difficulty turning head from side to side, loss of muscular control, stiff joints or neck, inadequate hand/eye coordination, medical condition that affects your judgment, dizziness or balance problems, or missing limbs.
Driver History / Vehicle Questions
Answer fixed: Yes