Customer Information

*(Required)
First Name*	:	First Name is Required! Letter, dash, spaces only!
Middle Name	:	Letters only!
Last Name*	:	Last Name is Required! Letter, dash, spaces only!
Suffix	:	Letters only!
Birth Date(mm/dd/yyyy) *	:	Birth Date is Required! Invalid Date Format!
Re-enter Birth Date (mm/dd/yyyy)*	:	Birth Date is Required! Invalid Date Format! Birth Dates must match!
License/ID/Case Number*	:	Credential No is Required! State is Required!
Phone Number *	:	Phone No is Required! Invalid Phone#
SSN(Last 4 digits)	:
Re-enter SSN(Last 4 digits)	:	Last 4 digits of SSN must match!
Email Address*	:	Email Address is Required! Please Enter Valid Email ID!
Re-enter Email Address*	:	Email Address is Required! Please Enter Valid Email ID Emails must match!

**Please DO NOT DRIVE until you have confirmed that your status is valid and you have a current driver license or learner permit in your possession.**

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State of Connecticut Department of Motor Vehicles