DLD 23A (Rev. 9-05)
Request for Re-Evaluation
This form must be accompanied by an affidavit from a physician indicating that the physician agrees the driver
designated below should be re-examined to determine whether or not they could safely operate a motor vehicle.
I believe the following driver should be re-examined:
NAME
ADDRESS
SSN
DOB
DRIVERS LICENSE NUMBER
This driver’s difficulties were brought to my attention because:
The driver was involved in an accident.
The driver committed a traffic violation.
Other (please explain)
Please describe in detail the nature of the disability and how it impairs this person’s ability to drive
safely. Describe the incident and list the names of any witnesses. In addition, please indicate the
date of the occurrence. If additional space is needed, please attach another sheet of paper.
I hereby certify all statements on this affidavit are true and correct to the best of my knowledge. I agree
and understand that if an administrative hearing is held based on my request for re-examination of this
driver, I may be required to appear and testify
.
Name (please print)
Signature Drivers License Number
Relationship to Driver Telephone Number
Address
Subscribed and sworn before me this day of , 20
Notary Public or
DMV Representative
555 Wright Way
Carson City, NV 89711
Reno/Sparks/Carson City (775)
684-4DMV (4368)
Rural Nevada (877) 368-7828
Fax: (775) 684-4829
Website: www.dmvnv.com
