STATE OF CONNECTICUT

DEPARTMENT OF MOTOR VEHICLES

[Link]/dmv We'd like to hear from you!

Date: 6/22/2023 CONGRATULATIONS

PAVANKUMAR MADDALA
YOU HAVE SUCCESSFULLY SCHEDULED YOUR LEARNER PERMIT VISION AND KNOWLEDGE TEST APPOINTMENT
ALL DOCUMENTS PRESENTED TO THE DMV MUST BE ORIGINAL OR CERTIFIED COPIES.
PHOTOCOPIES WILL NOT BE ACCEPTED.

BE PREPARED. Bring the following REQUIRED documents with you!

Please refer to the document checklist on page 3 or at [Link]/dmv/RealID for a complete list of acceptable documents to
answer 1-5 below.
1. IDENTITY: You must present two forms of identification. At least one of the documents must be from the primary document list.
My primary document I will present is: , my 2nd is

2. SOCIAL SECURITY NUMBER: You must present one of the following to prove your social security number (SSN): Social Security
Card, 1099 or W-2 containing the full number. The 1099 or W-2 will not be used for proof of identity. Non-US Citizens not eligible for a
SSN must present proof of ineligibility from the Social Security Administration (SSA). W2 and 1099 must have been issued within 5
years.
My social security number verification I will present is: SS Card W2 1099 Proof of ineligibility from SSA

3. CONNECTICUT RESIDENCY: You must present two different pieces of mail or electronic mail from two different sources showing
your name and Connecticut residence address, dated within 90 days unless stated otherwise on document checklist.
My 1st proof of residency I will present is: , my 2nd is

4. LEGAL PRESENCE IN THE UNITED STATES: Non U.S Citizens only.

My proof of legal presence I will present is:

5. NAME CHANGE DOCUMENTS, if applicable: If there have been multiple name changes, you must provide documentation to
prove the continuity of the names.
My name change document(s) I will present is(are):

6. Current non-driver ID, if issued, which must be surrendered. Visit our website at [Link]/dmv/exchange to verify if you qualify for an
Exchange.
7. A printout of this appointment confirmation page.

8. The completed R229 application, page 2.

Bring your glasses or contact lenses, if needed, for testing. If you fail the vision test you will not be able to proceed to the
knowledge test and will be required to reschedule.
If under 18, parent or legal guardian must accompany you with their identification to sign the parental consent
(Legal guardian must present certificate of legal guardianship from the court).
If parent or legal guardian is unable to come with you, you must present a notarized certificate of parental consent form (Form
2-D).This form can be found on our website [Link]
Study the Connecticut Driver's Manual You will be required to reschedule, wait seven days and repay the test fee if you fail the test.

If you fail to comply with the above requirements you will not be allowed to test and must reschedule your appointment.

If you fail to appear at your scheduled time you will be required to reschedule and repay the test fee.

If you are unable to keep this appointment and reschedule within two days of your appointment date you will be required to repay
the test fee. If you cancel within two days of your appointment date you will not be eligible for a refund of the test fee.

APPOINTMENT DETAILS
PIN: ERBS4SXY Fee Paid: Learner Permit $19.00
Date/Day/Time: 6/27/2023 Tuesday 10:45 AM Test Fee $40.00
Testing Location: 1625 Highland Ave., Cheshire, CT, 06410 Total
$59.00
Authorization Code: 09125D Payment Date: 6/22/2023
PIN: ERBS4SXY 6/27/2023 Tuesday 10:45 AM 1625 Highland Ave., Cheshire, CT, 06410 $59.00
DMV USE OUT OF STATE DRIVE ADD/REMOVE
NEW TRANSFER ONLY ENDORSEMENT/RESTRICTION EXCHANGE RETEST
ONLY

APPLICATION FOR A NON-COMMERCIAL

LEARNER PERMIT AND/OR DRIVER LICENSE STATE OF CONNECTICUT
R-229 REV. 6-2014 DEPARTMENT OF MOTOR VEHICLES
On The Web At [Link]/dmv
INSTRUCTIONS: Complete 1-18, then present
1. Required Identification Documents & Proof of Connecticut
Residency: see "Acceptable Forms of ID" at [Link]/dmv
2. 16 and 17 year olds: Certificate of Parental Consent Form 2D
NO FEE LEARNER PERMIT NUMBER DATE OF ISSUE
(if not accompanied by authorized individual)
3. Applicable Fees US MILITARY

1. APPLICANT'S NAME (Last, First, Middle, Suffix) 2. GENDER 3. DATE OF BIRTH 4. HEIGHT 5. COLOR OF EYES
MADDALA, PAVANKUMAR M F X 5/15/1985 ft. in.
6. MAILING ADDRESS (No., Street, City or Town, State, Zip Code) 7. RESIDENCE ADDRESS (If different from mailing address)
92 SPRING STREET, NEW HAVEN, CT, 06519
8. US CITIZEN? If "NO", list ALIEN REGISTRATION NO. 9. CONNECTICUT 10. DO YOU WANT TO BE IN THE ORGAN/TISSUE DONOR 11. DAYTIME PHONE NO.
RESIDENT? REGISTRY? If yes, you are agreeing to be a donor
and the designation will be on your
Yes No Yes No Yes No license. ( ) 646 249-4662
12. SOCIAL SECURITY NUMBER 13. LIST ANY OTHER NAMES EVER USED (Alias, Maiden, etc) 14. E-MAIL ADDRESS
[Link]@[Link]
QUESTIONS YES ( ) NO ( )

15. Have you previously failed a driver's license FAILED LOCATION DATE
examination in Connecticut? VISION KNOWLEDGE ROAD
PERMIT, LICENSE OR ID NO. (9 digits) EXPIRATION DATE NO. OF YEARS
16. Do you now, or have you ever held a Connecticut Learner Permit,
License or Non-Driver Identification Card?

17. Do you now, or have you ever held an Operator's License or STATE DRIVER LICENSE OR ID. NO. EXPIRATION DATE NO. OF YEARS
Identification Card from another state?
IN WHAT STATE(S)?
18. Is your privilege to operate a motor vehicle suspended or subject to
suspension in Connecticut or in any other state?
Section 14-36l of the Connecticut General Statutes requires the Commissioner to transmit my
SELECTIVE information to the Selective Service System. By signing and submitting this application, I consent I hereby certify that I do not
to be registered with the Selective Service System, provided I am at least age 16 but under age MEDICAL have any health or vision
SERVICE 26 and meet the criteria for registration in accordance with the Military Selective Service Act. If I problems or conditions that
CERTIFICATION
CONSENT am under age 18, I understand that my information will be transmitted to Selective Service but I prevent me from driving safely.
will not be registered until I reach age 18.
The information provided to the Commissioner of Motor Vehicles herein is SIGNATURE OF APPLICANT DATE SIGNED
subscribed by me, under penalty of false statement, in accordance with
CERTIFICATION the provisions of Section 14-110 and 53a-157b of the Connecticut General
BY APPLICANT Statutes. I understand that if I make a statement which I do not believe to
be true, with the intent to mislead the Commissioner, I will be subject to
prosecution under the above-cited laws. X
DO NOT WRITE BELOW THIS LINE - OFFICE USE ONLY
PROOF OF TYPE OF IDENTIFICATION SHOWN EXAMINERS INITIALS STAMP NO.
I.D. SCANNED FIRST VISIT
IDENTIFICATION
FULL LEGAL If different than entered in name section above (# 1)

NAME
PARENTAL I hereby request that a learner's permit RELATIONSHIP TO MINOR SIGNED (Authorized Consenter) CONSENTER'S LIC. NO. OR OTHER I.D.
CONSENT and/or license be issued to the minor
AGE 16 OR 17 ONLY filing this application. X
VISION VISUAL AID USED RESULTS AGENTS INITIALS PUNCH NO. AND PUNCH
SCREENING NONE GLASSES/CONTACTS PASSED FAILED
RESULTS
KNOWLEDGE TEST RESULTS APPLICANTS INITIALS CONFIRMING IDENTIFICATION
DOCUMENTS RETURNED
TEST COMPUTER/AUDIO WRITTEN WAIVED PASSED FAILED
ISSUE PERMIT WITH CORRECTIVE ISSUE DRIVE ONLY
PERMIT ISSUE LEARNER PERMIT ISSUE MOTORCYCLE PERMIT LENSES (B-RESTRICTION) (Y-RESTRICTION)
AGENT I hereby certify that I have examined the applicant's identity SIGNED (Agent) PUNCH NO. AND PUNCH DATE SIGNED
documents and the test results stated herein are true and
CERTIFICATION correct. X
CLASSROOM SCHOOL NAME COMMERCIAL SCHOOL LICENSE NO. DRIVER EDUCATION CERTIFICATE NO.

DRIVER INSTRUCTION
TRAINING PRACTICE SCHOOL NAME (If same as above print "same") COMMERCIAL SCHOOL LICENSE NO. DRIVER EDUCATION CERTIFICATE NO.
DRIVING
I hereby subscribe and certify under penalty of false statement, in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes that I
understand that if I make a statement, which I do not believe to be true, with the intent to mislead the Commissioner I will be subject to prosecution under the above-cited laws, that,
HOME I am qualified under Section 14-36, of the Connecticut General Statutes, over 20 years of age, have no suspensions within the previous 4 years and the Applicant has received the
required training, including the equivalent of 22 hours classroom training; 40 hours on-the-road instruction; the 8 hours Safe Driver course, including a 2 hour Parent Training, as
TRAINING/ supported by a parent log and/or driving school certificate.
COMMERCIAL 1 2 3 SIGNATURE OF INSTRUCTOR (Home Training/Commercial) OPERATOR LICENSE NUMBER OR
SCHOOL LICENSE NUMBER
TRAINING Home Training Comm/Sec and Home Comm/Sec Only
22 hr class equiv 30 hrs class/minimum 30 hrs class
CERTIFICATION 40 hr on-the-road 8 hr safe driving plus home 40 hrs on-the-road
8 hr safe driving training 40 hrs on-the-road X
SPECIAL EQUIPMENT
ROAD TEST WAIVED PASSED FAILED
AND LICENSE NON-COMMERCIAL CLASS ENDORSEMENT RESTRICTIONS (Circle All Applicable)
INFORMATION
D M Q B C D E F G R U Y
AGENT I hereby certify that I have verified the applicant's SIGNED (Agent) PUNCH NO. AND PUNCH DATE SIGNED
identity and the test results stated herein are true
CERTIFICATION and correct. X
REAL ID DOCUMENT CHECKLIST Connecticut DMV
For Identity Verification
To obtain a new learner’s permit, driver’s license or identity (ID) card, or to obtain a verified driver’s
license or ID card, you will need to provide valid/unexpired, original documents, or certified copies.
Out of state learner’s permits are not transferable.

Photocopies, notarized photocopies, non-certified copies of forms that require certification, and damaged
or mutilated documents are not acceptable. DMV will scan and store images of all original documents.

Two (2) forms of the same identification will not be accepted. If any document presented is in a language
other than English, it must be translated by a DMV approved translator. [Link]/dmv/RealID

You must satisfy sections A , B , C and if applicable, D and E .

A 2 IDENTITY DOCUMENTS: SECONDARY document list

You must present two (2) forms of identification; at least £ Social Security Card (Not laminated or metal. Sixteen (16) and
one of the documents must be from the Primary document older must sign)
list. £ Connecticut issued ID card, driver’s license or learner’s permit
(You may be required to surrender your driver’s license or ID
PRIMARY document list card)
US born £ Out of State US photo driver’s license
£ US or US Territory Birth Certificate or Registration of Birth £ US Territory or Canadian photo driver’s license
(Hospital issued and Puerto Rico issued prior to July 1, 2010 £ Out of State US or Canadian issued photo learner’s permit
not acceptable; foreign place of birth see Non-US Born) £ Certified school transcript (School photo ID is not acceptable)
£ US Passport or Passport Card £ Baptismal certificate or similar document
Non-US born £ Marriage or Civil Union Certificate (certified copy issued by
£ US Passport or Passport Card town/city)
£ Foreign Passport w/ supporting documents (See Section D £ Court Order: Must contain full name and date of birth (i.e. name
below)* change, adoption, marriage or civil union dissolution) Does not
£ Certificate of Naturalization (N-550 or N-570)* include abstract of criminal or civil conviction
£ Certificate of Citizenship (N-560 or N-561)* £ Connecticut State Permit to Carry Pistols or Revolvers
£ Permanent Resident Card (I-551)* £ US Military ID or dependent card with photo
£ US Consular Report of Birth Abroad (FS-240, DS-1350 £ Military discharge/separation papers (DD-214)
or FS-545) £ State or Federal Employee Identification with signature and
photo and/or physical description with or without date of birth
FULL LEGAL NAME £ CT Department of Correction certificate (CN101503)
By law, the full name shown on the Primary document is £ Pilot’s license (issued by the US DOT Federal Aviation
your legal name and will be printed on your card. If your Administration)
name is different than the Primary document, see £ Employment Authorization Document (I-766 or I-688B)
Section E below. £ Veteran Health Identification Card (VHIC)
* Subject to Systematic Alien Verification of Eligibility (SAVE) £ Federally Recognized Tribal Member ID card
(See Section D below) £ DHS Trusted Traveler Cards (Global Entry, NEXUS, SENTRI,
FAST)

B SOCIAL SECURITY NUMBER:

By law, you must provide your Social Security number, which Non-US Citizens who are not eligible for a Social Security number
must be verified with the Social Security Administration. must present an ineligibility letter from the Social Security
Administration.

C 2 FORMS OF PROOF OF CONNECTICUT RESIDENCY:

You must provide two (2) different forms of documentation from £ Bank statement showing the bank’s name and mailing address
the list below to prove Connecticut residency. £ Pre-printed pay stub showing your employer’s name and address
£ Property or excise tax bill dated within the previous twelve
These documents must be from two (2) different sources and (12) months
MUST: £ Valid unexpired CT driver’s license, learner’s permit or ID card
with the same address
• Show your name and your Connecticut residence address £ Current valid homeowner’s, renter’s policy or motor vehicle
• Be dated within ninety (90) days (unless stated otherwise insurance card or policy dated within the previous 12 months
below) £ Current valid Connecticut motor vehicle registration
• Be computer generated (typed) £ Current motor vehicle loan statement for a motor vehicle
• Be a hard copy registered in your name
NOTE: The parent(s) or legal guardian(s) residing at the same £ Residential mortgage, lease or rental contract showing
address of a minor may provide any two (2) of the acceptable signatures from all parties needed to execute the agreement and
documents, addressed to the parent(s) or legal guardian(s), to dated within the previous twelve (12) months
prove the minor’s residency. £ Change-of-address confirmation from the United States Postal
Service showing your prior and current address (Form CNL107)
Acceptable Documents £ Official school records showing enrollment
£ Postmarked mail (address may be handwritten) £ Report card
£ Bill from a bank or mortgage company, utility company, credit
card company, doctor or hospital

D LEGAL PRESENCE IN THE UNITED STATES (Non-US born):

Legal status will be verified using Systematic Alien • Non-US Citizens who are not eligible for a Social Security number
Verification of Eligibility (SAVE) which may take ten (10) must present an ineligibility letter from the Social Security
business days or more. Administration and are not qualified for a verified driver’s license
or ID card.
£ US Passport or Passport Card
£ I-94 • Only US Citizens and Permanent Residents are eligible for a
£ I-551 stamp in foreign passport verified driver’s license or ID card.
£ Permanent Resident Card or Resident Alien Card
£ Employment Authorization Document (I-766 or I688B) • B1/B2 visitor status is NOT eligible to obtain a CT driver’s license
£ Refugee Travel Document or ID card.
£ F1 requires I-20 and I-94
£ J1 requires DS2019 and I-94

E NAME CHANGE DOCUMENTS (if applicable): If there have been multiple name changes, you must provide
£ Marriage or civil union certificate (certified copy issued by documentation to prove the continuity of the names.
town/city)
£ Marriage or civil union dissolution NOTE: Your new name must match the name that is on file with the
£ Probate court name change document Social Security Administration (SSA). Visit the SSA first to change
£ DHS Petition for Name Change (USCIS Form N-662) your name. Allow at least forty-eight (48) hours for SSA to update its
system.

If you have a question regarding acceptable documents, please call the DMV Contact Center at 860-263-5700.

DI-3 REV. 5-2023