SSN:

Disclosure of the applicant's social security number is made mandatory by Neb. Rev. Stat. 60-484. The number shall be used only to furnish driver record information for males between the ages of seventeen and twenty-six to the United States Selective Service System under Neb. Rev. Stat. 60-483; in connection with the verification of the status of any individual's driving record in this state or any other state, or for purposes of child support enforcement pursuant to Neb. Rev. Stat. 42-358.08 or 43-512.06; or to furnish information regarding an applicant or holder of a commercial driver's license with a hazardous materials endorsement to the Transportation Security Administration of the United States Department of Homeland Security or its agent; or to furnish information to the Nebraska Department of Revenue under Neb. Rev. Stat. 77-362.02

RECORD CHECKS:

All applicants are subject to record checks through the Problem Driver Pointer System and the Commercial Driver's License Information System.

DUI NOTICE:

If you are arrested for operating or being in actual physical control of a motor vehicle while under the influence of alcoholic liquor or drugs, the arresting officer may require you to submit to a chemical test or tests of your blood, breath or urine to determine its concentration of alcohol or drugs. Refusal to submit to such test or tests is a separate crime of which you may be charged.

SEX OFFENDER REGISTRATION NOTICE:

State law requires persons convicted of sex offenses to register with the sheriff in the county where they reside. Failure to register is a crime. Contact your county sheriff for further information.

AFFIRMATION:

The type of permit, license or State ID Card I am making application for is not currently cancelled, suspended, revoked or surrendered to any court or governmental agency. By making this application, any previously issued document of the same type becomes null and void at the time of issuance and may not be used for operating privileges, identification or surrendered as evidence for a renewal permit, license or State ID Card.

For purposes of complying with Neb. Rev. Stat. 60-484-04, I attest: I am a UNITED STATES CITIZEN

To the best of my knowledge and belief, I declare under penalty of election falsification that:

1. I live in the State of Nebraska at the address provided in this application;
2. I have not been convicted of a felony or, if convicted, it has been at least two years since I completed sentence for the felony, including any parole term;
3. I have not been officially found to be non compos mentis (mentally incompetent); and
4. I am a citizen of the United States.

Any registrant who signs this application knowing that any of the information in the application is false shall be guilty of a Class IV felony under section 32-1502 of the statutes of Nebraska. The Penalty for a Class IV felony is up to five years imprisonment, a fine of up to ten thousand dollars, or both.