Driver’s License Review
555 Wright Way
Carson City, NV 89711
Reno/Carson City – (775) 684-4DMV (684-4368)
Las Vegas – (702) 486-4DMV (684-4368)
dmvnv.com
Eye Examination Certificate
(NAC 483.310, 483.340)
Name of Applicant
(LAST Name) (Fi
rst Name) (Middle Name)
Applicant’s Date of Birth
Nevada Driver’s License No.
(MM/DD/YYYY)
Applicant’s Address
Applicant’s Phone Number ( )
I, , certify that I have examined the above-named applicant
(Printed Name of Physician or Optometrist Licensed to Practice in Nevada)
and offer the following record of the eye examination.
With With New Rx
Without Rx
Current Rx If Being Changed
Right Eye........................................................................................................20/ 20/ 20/
Left Eye ..........................................................................................................20/ 20/ 20/
Both Eyes.......................................................................................................20/ 20/ 20/
Could visual acuity deficiency be corrected with glasses? ......................................................................................Yes No
Are glasses being fitted? …Yes No Are there any progressive abnormalities? ....Yes * No
Will the applicant’s condition (as described above) impair his/her ability to safely operate a motor vehicle? .Yes * No
*If Yes, please further explain the case and recommend restrictions:
Duly licensed to practice in Nevada.
Physician’s Signature
Physician’s Office Street Address Date of Examination
City, State, and Zip Code
Physician’s Office Telephone Number Applicant’s Signature
PLEASE NOTE: This Eye Examination Certificate must be presented within
90 days of the date the examination was
performed by a physician or optometrist licensed to practice in the State of Nevada.
DP18 (Revised 12/2007; replaced form DLD18.)
