Fillable Form DL-41 Mississippi Driver License Application

What is the Mississippi Driver’s License Application Form?

DMV Form DL-41, Application for Mississippi Driver License, or also referred to as the Mississippi Driver’s License Application Form, is used by residents from Mississippi to apply for a driver’s license, learner’s permit, name change, commercial driver’s license, or identification card. Before applying for a new license, Mississippi residents must first surrender their out-of-state driver’s licenses to the Mississippi Department of Public Safety (MS DPS).

How to fill out the Mississippi Driver’s License Application Form?

Mississippi residents can download and print a PDF copy of the Mississippi Driver’s License Application Form from the Mississippi Department of Motor Vehicles (MS DMV) and the Mississippi Department of Public Safety (MS DPS) websites that they can manually complete. They can also fill out the Mississippi Driver’s License Application Form electronically on PDFRun.

To fill out the Mississippi Driver’s License Application Form, you must provide the following information:

Section 1

Mark the appropriate box which corresponds to the type of application you would like to file. You may select:

• Other state
• Learner’s permit
• Name change
• Commercial Driver’s License (CDL)
• Class D Commercial License
• Identification card
• Surrender
• Commercial Driver’s License (CDL)
• Regular
• Motorcycle

Full Name

Enter your full legal name.

Last Name

Enter your legal last name.

First Name

Enter your legal first name.

Middle or Maiden

Enter your legal middle name or maiden name.

Suffix

Mark the appropriate box which corresponds to your suffix. You may select:

• Jr.
• Sr.
• II
• III
• IV
• Other - Enter your suffix.

Home Address

Enter your home address.

Apartment Number

Enter your apartment number.

City

Enter your city.

State

Enter your state.

ZIP Code

Enter your ZIP code.

Assigned Number

Enter the number assigned to you.

Social Security Number (SSN)

Enter your social security number (SSN).

Date of Birth

Enter your date of birth.

Month

Enter the month of your birth.

Day

Enter the day of your birth.

Year

Enter the year of your birth.

Age

Enter your age.

Race

Enter your race.

Sex

Enter your sex.

Height

Enter your height.

Weight

Enter your weight.

Eyes

Enter the natural color of your eyes.

Hair

Enter the natural color of your hair.

Section 2

Items 9 through 11 must only be completed by applicants who would like to apply for a commercial driver’s license (CDL).

Item 1

Mark YES if you have ever held a driver’s license in any state in the past 10 years; otherwise, mark NO. If you have marked YES, enter the state, the year, and the driver’s license number of your previous license.

Item 2

Mark YES if you have ever held an identification card in any state in the past 10 years; otherwise, mark NO. If you have marked YES, enter the state, the year, and the identification card number of your previous card.

Item 3

Mark YES if you are subject to any disqualification under 49 Code of Federal Regulations (CFR) 383.51, Disqualification of Drivers, or any license suspension, revocation, or cancellation under the State Law, and have a driver’s license from more than one state or jurisdiction; otherwise, mark NO.

If you have marked YES, enter the state, the year, and the reason for your disqualification, license suspension, revocation, or cancellation.

Item 4

Mark YES if you have ever been denied a driver’s license; otherwise, mark NO. If you have marked YES, enter the reason you have been denied a license.

Item 5

Mark YES if you are currently being treated for diabetes; otherwise, mark NO. If you marked YES, enter if you are currently taking a shot or a pill for diabetes treatment.

Item 6

Mark YES if you have any physical defects which would interfere with your ability to operate a motor vehicle safely; otherwise, mark NO. If you have marked YES, explain your physician defects.

Item 7

Mark YES if you are a citizen of the United States; otherwise, mark NO. If you have marked YES, enter the date of your citizenship.

Item 8

Mark YES if you would like to indicate your desire to become an organ donor and have such marking denoted on your driver’s license or identification card; otherwise, mark NO.

Item 9

Mark YES if the drive test vehicle representative of the class you will drive; otherwise, mark NO.

Item 10

Mark YES if you are exempt from the requirements of 49 Code of Federal Regulations (CFR) 391, Qualifications of Drivers; otherwise, mark NO. If you have marked YES, enter the reason why you are exempted.

Item 11

Mark YES if you meet the qualification requirements of 49 Code of Federal Regulations (CFR), Qualifications of Drivers; otherwise, mark NO.

Consent to Registration with the Selective Service System (SSS)

By submitting this application, you are consenting to registration with the Selective Service System (SSS). You must affirm that you are the person named and described in this MS Driver's License Application Form and that the statements written here are true and correct. You must understand that your driver’s license will be subject to suspension by knowingly and willingly falsifying any information you have given.

Signature of Applicant

Affix your signature.

Date

Enter the current date of signing.

Section 3

Vote Registration

Mark YES if you would like to register to vote; otherwise, mark NO.

Receipt Number

Enter all applicable receipt numbers.

Learner’s Permit Receipt Number

Enter all applicable learner’s permit receipt numbers.

Application Fee

Enter all applicable application fees.

End Receipt

Enter all applicable end receipts.

General Knowledge

Enter all of your general knowledge.

Air Brakes

Enter all applicable air brakes information.

Combination

Enter all applicable information about your combination.

Motorcycle

Enter all applicable motorcycle information.

Double/Triples

Enter all applicable trailer information.

Tanker

Enter all applicable tanker information.

Passenger

Enter all applicable passenger information.

School Bus

Enter all applicable school bus information.

Hazardous Materials (HAZMAT)

Enter all applicable information about any hazardous materials.

Pre-Trip

Enter all applicable information about the pre-trip truck inspection.

Basic Control

Enter all applicable information about the vehicle’s basic control.

Medical Card Expiration Date

Enter the date when your medical card will expire.

Road Test

Enter all applicable road test information.

Vehicle Information

Enter your vehicle information.

Tag Number

Enter the tag number of your vehicle.

Type

Mark the appropriate box which corresponds to the type of your tag number. You may select:

• P
• F

Class of Driver’s License

Enter all applicable driver’s license class information.

Endorsements

Enter all applicable information about your endorsements.

Restrictions

Enter all applicable information about your restrictions.

Acuity

Enter your visual acuity and fill out the following boxes:

• L20
• R20
• B20

Acuity Correction

Enter your corrected acuity and fill out the following boxes:

• L20
• R20
• B20

Expiration Date of Driver’s License

Enter the expiration date of your driver’s license.

Residency Document

Enter which type of residency document you have brought.

Surrender/Exempt from Test

Mark the box if you have surrendered the test or have been exempted from the test.

Social Security Administration (SSA) & Supplemental Security Income (SI) Checked

Mark the box if you have had your accounts checked.

National Crime Information Center (NCIC) Checked

Mark the box if you have had your background checked.

Photo Number

Enter your photo number.

Name Change

Mark the appropriate box which corresponds to the reason for your name change. You may select:

• Marriage license
• Divorce
• Court order

Document Identification Number

Enter your document identification number.

Previous Name

Enter your full previous name.

Mother’s Maiden Name

Enter your mother’s maiden name.

Place of Birth

Enter your place of birth.

Date of Birth Change

Enter your changed birth date.

Insurance Policy Number

Have your examiner enter the insurance policy number.

Rehabilitation Permit

Have your examiner enter the rehabilitation permit if it is applicable.

Examiner

Have your examiner enter his or her full legal name.

Identification Document

Have your examiner enter the name of the identification document.

Badge Number

Have your examiner enter his or her badge number.