Request for Application

First Name

Last Name

Middle Name

Maiden Name

Name as you wish it to appear

Birth Date

SSN (last 4 digits)

Cell Phone

Home Phone

Designation

LMBT

Gender

Female

Male

Other

Are you a US Citizen?

Yes

Country in which you hold citizenship

Copy of Visa or Green Card

Upload your Visa or Green Card document here. (pdf)

If you have ever been licensed in NC before, please list your previous license number

Address

City

State

Zip

County

Online payment and access to application