You are qualified for a 5-year driver license based upon your good driving record. Sign your name below. You will receive your-renewal by mail (RBM) after all required information is received. Your RBM will be a new driver license with the most recent photo from the photo database.

Please answer the following medical questions by entering an *X* in the yes or no boxes below. This information is for confidential use by DMV.

Question 1. Since you received your last-license, have you had a lapse of consciousness or developed any disease, disorder or disability which could affect your ability to drive safely?

Question 2. Since you received your last license, have you had a change in your vision which cannot be corrected with glasses or corrective contact lenses and which could affect your ability to drive safely?

 

MEDICAL INFORMATION

Health

DMV must be notified if, within the last three years, you have :
( ) Experienced a loss ot consciousrness, or

( ) Had any episode of marked confusion caused by any condition which may bring about recurring lapses, or

( ) Had any disease, disorder, or disability which affects your ability to drive safely.

Examples of the above are: ( ) Epilepsy ( ) Diabetes ( ) Stroke ( ) Drug or alcohol addiction

Vision
Vision changes since your last renewal must be reported to DMV. Examples are:
( ) Cataracts ( ) Diabetic retinopathy ( ) Glaucoma