1. Last name:
Patterson
2. First Name:
Timothy
5. Email Address:
*****************
6. Telephone:
215-649-0154
7. *Passport #:
8. *Passport Date of Issue#:
4/15/1999
New Orleans, LA
Baton Rouge, LA
1/16/1979
12. Nationality:
American
a1234567
CA
12/20/2005
12/20/210
I understand that this international driver's license is in no way intended to replace a suspended
or revoked driver's license from the United States or any other country, and I am not applying for
this international driver's license to use as such. I do further understand that this international
driver's license will become null and void if a license is issued and the above is the actual
Intention of the applicant. I further release IDL International, Inc. from any and all said liability
caused by any misrepresentation on my part. I additionally release IDL International, Inc. from
any and all liability caused by applicant's failure to comply with any local, state, national, or
international law.
IDL INTERNATIONAL'S LIABILITY LIMITED TO THE REFUND OF LICENSE FEE.
Timothy Patterson
17.Applicant Signature:
* Not Mandatory
Credit cards (VISA, MasterCard or American Express) are accepted for YOUR convenience. All credit card
transactions will be billed an additional $5.00 per license to offset processing fees.
341406194234099
Expiration Date:
Name on Credit Card:
Billing Address of
Credit Card:
02/2010
Timothy Patterson
1802 Parkway Street
Apt. # 178
San Diego, CA 90121
Authorized Card
Holder Signature:
Timothy Patterson