Fillable Request for Re-Examination (Department of Motor Vehicles )

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Request for Re-Examination (Department of Motor Vehicles )

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  • 7 check-boxes
  • 20 other fields

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File type: PDF

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DLD23 (Rev. 7-2006)
Central Services Division
License Review
555 Wright Way
Carson City, NV 89711
Reno/Sparks/Carson City (775) 684-4DMV (4368)
Las Vegas Area (702) 486-4DMV (4368)
Fax: (775) 684-4829
dmvnv.com
Request for Re-Examination
Agency/Individual Requesting Re-Examination (please check one):
Law Enforcement, Badge # ___________ State Agency Other
Please specify the law enforcement agency, state agency or other facility completing this request:
______________________________________________________________________________________________________
I believe the following driver should be re-examined:
NAME
ADDRESS
SSN
DOB
DRIVER’S 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)
I have observed the following:
The driver appears to have a physical disability and/or illness, which appears to affect his/her ability to drive
safely.
The driver appears to have a mental or psychiatric disorder, which interferes with his/her ability to drive
safely.
The driver has had a lapse of consciousness, dizziness, fainting spell, or a seizure due to injury or illness.
Other (please explain)
Please describe the incident; explain the driver’s impairment and how
it affects his or her driving ability
(please attach additional sheets as necessary).
Date of Incident
Name (please print)
Signature
Date Telephone Number
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Request for Re-Examination (Department of Motor Vehicles )

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Completed 24 December 2020

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