For Department Use Only
Yes No
Drive history record checked. State _________ Comments ___________________________
Vision meets standards Comments ____________________________________________________
Approved to continue with licensing process Comments ____________________________________
DMV Representative Signature ________________________________________________ Date ____________
555 Wright Way
Carson City, NV 89711
Reno/Sparks/Carson City (775) 684-4DMV (4368)
Las Vegas Area (702) 486-4DMV (4368)
dmvnv.com
Application For Approval To Drive With Bioptic Lenses
Driver
Name ____________________________________________________________________________
Date of Birth ________________________ Social Security Number ________________________
Mailing Address ______________________________________________________________________
Have you ever been licensed in a state other than Nevada? Yes No
If Yes, State? _____________ DL No. ______________________ Exp. Date _____________
Applicant Signature _______________________________________ Date _________________
Licensed Vision Specialist
Static acuity through the telescopic portion of the devise _____________________________________
Right Left Both
Best corrected vision through the carrier lens 20 / 20 / 20 /
Field of vision __________ degrees Is the condition stable or progressive (circle one)
The following license restrictions are required for drivers who wear bioptic lenses:
z Corrective Lenses z Outside mirrors on both sides of vehicle
z Daylight driving only z Speed not to exceed 45 m.p.h.
z Yearly vision examination z Yearly driving examination
z Bioptic telescopic lenses
Do you recommend any additional driving restriction? ________________________________________
Physician’s Signature __________________________________________ Date ____________
DLD-98 (Revised 12/01)
