Name

Date of Birth

NJ Driver's License Number or MVC Non-driver ID Number
If you DO NOT have a NJ Driver's License or MVC non-Driver ID, provide the last 4 of your Social Security Number.

"I swear or affirm that I DO NOT have a NJ Driver's License, MVC Non-driver ID or a SSN"

Home Address

Mailing Address If different from Home Address.

Last Registered Address

Former Name If making a name change.

Optional Questions

Gender

I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as official documentation and is subject to penalty for perjury. Full Name: Today's Date: