Fillable UT LICENSE # Visual Acuity: Passed Eye Statement (Utah DRE)

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UT LICENSE # Visual Acuity: Passed Eye Statement (Utah DRE)

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The UT LICENSE # Visual Acuity: Passed Eye Statement (Utah DRE) form is 3 pages long and contains:

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  • 2 check-boxes
  • 125 other fields

Country of origin: US
File type: PDF

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Full
Legal
Name
Middle
Date of Birth
Gender
UT Residence Address
Social Security Number or ITIN
This information will not show on your driver license or ID card
City Zip Code
Mailing Address
City State Zip Code
Height Weight
FT.
IN.
Hair Color
Eye Color
Applicant’s
Mother’s
Place of
Maiden
Birth State/Country
Name
Last
First
NOTICE: APPLICANT MUST ANSWER ALL QUESTIONS.
Print the name of the person signing for minor:
Father
Mother Guardian
DLD6a Rev. 2/21
DLD Office Use Only:
EL LERN ORG LERN
DPC DL CDL ID IDD
LTID LTDL LTCDL MVP
Class: A B C D
End. H N X Z P S T M
Visual Acuity: Passed Eye Statement
Restrictions: A B K L G V 6
Motorcycle Restrictions:
2 3 5
Testing: Written Road Ref/Asyl
CDLIS: CSOR ADD DRIVER
CDL:
YES
YES
NO
YES
PDPS:
SB:________________________________
License Surrender:
NO
IDC:
NO
Iss.: _____________ Exp: _____________
State: ___________ End.: _____________
License #: __________________________
Total $: __________ Trans #: __________
Initials: ______
Date Stamp: ________________________
YES NO Are you a U.S. Citizen?
YES
YES
Are you a legal permanent resident alien or a U.S. National?
If you are a citizen of another country, do you have evidence of
lawful presence in the United States?
YES NO
YES
NO
YES
YES
NOYES
NO
NO
NO
YES
YES NO
YES
NO
YES
NO
YES
NO
Do you claim to be disabled under the Americans with Disabilities Act?
YES
NO
UT LICENSE #
UT ID #
J:____________________
Translator: Y / N
Station Code: ___ Emp. #: ___ Initials: ___
Name Change:
From: _____________________________
To: _______________________________
ID #1: _____________________________
ID #2: _____________________________
Address Verified: ____________________
Full Legal Name:
__________________________________
DOB: __________ Iss Date: ___________
BC PP DHS #: ______________________
Iss. Agency: ________________________
Required Docs Scanned: YES
SSN: _______________ Date: __________
SAVE: Approved/Exp.: ________________
Emp. #: __________ Date: _____________
FirstLast Suffix
Number/Street/Apartment
mm
/dd/yyyy
Email Address
Phone
YES NO
I would like to register my desire to help others by being an organ, eye, and tissue
donor (life-saving anatomical gift.)
Are you a U.S. Military Veteran?
If yes, do you authorize sharing this information with the Utah Division of Veterans
Affairs for the purpose of identifying veterans and disseminating veteran benefit
information?
If you have been honorably discharged from the U.S. military, would you like to have a
VETERAN indicator on your driver license or ID card? Provide a DD214 or Veterans
Record/Notice of Separation indicating an honorable discharge.
Are you required to register as a sex offender with the State of Utah, any other state,
or with the U.S. Government?
Have you ever been issued, a driver license by another state, country or province? If
yes, list states/countries/provinces: ____________ # ____________ Exp. __________
If you are a CDL driver, have you been licensed in another state within the last 10
years? If yes, please list: _____ # ____________ I _____ # ____________
In the last 10 years, has your driving privilege been suspended, revoked, canceled,
denied or disqualified? If yes, State: _____ # ____________
Why? _______________________________________________________________
YES
NO
YES NO
NO
Do you wish to contribute a $2.00 donation to the "Friends for Sight" fund?
Do you wish to contribute a $2.00 donation to educate people about organ, eye and
tissue donation?
Do you wish to contribute a $1.00 donation to the "Mobility Assis
tance Fund?"
Do you claim to be disabled under the Americans with Disabiliti
es
Act?
Do you claim to be indigent and are applying for an ID card for
voting purposes?
_________________________ ____________________
______
________________________
______
_____________________
__________________________
PO Box/Number/Street/Apartment
_____________________
_____________________
_________________________________
________
________
________
___________________________________
_______________________________________________
_____________________
_____
_____
_______
_______________________________________
______________________
______________________
___________________________________________
Select
Select
Select
UT LICENSE # UT ID
#
Applicants who apply for or hold a license are responsible to report physical or mental health conditions to the
division. DO YOU HAVE, OR HAVE YOU HAD, ANY OF THE FOLLOWING CONDITIONS IN THE LAST FIVE
YEARS?
Diabetes:
Cardiovascular:
Pulmonary:
Neurologic:
Epilepsy:
Alcohol & Other
Drugs:
Vision:
Musculoskeletal:
Alertness or Sleep
Disorders:
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
YES NO
YES NO
YES NO
YES
NO
YES NO
YES NO
YES NO
YES NO
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Other:
Do you take insulin?
Do you have an uncontrolled heart condition?
Do you have an implantable cardioverter defibrillator (ICD)?
Have you lost consciousness or fainted in the last five years?
Do you have a pulmonary (lung) condition?
Is an inhaler the only medication prescribed for this condition?
Do you use supplemental oxygen?
Do you have, or have you had a neurological condition such as: Dementia, strokes, Alzheimer's, traumatic brain
injury, Multiple Sclerosis, or Parkinson's?
Do you have or have you had seizures in the last five years? Or,
Commercial Driver: Anytime during your life?
Do you have learning and memory difficulties which may interfere with driving safety?
Do you have a mental health condition such as schizophrenia, severe anxiety, or severe depression?
Do you use alcohol excessively, misuse prescription drugs, or use illegal drugs?
Have you been treated for alcohol or chemical dependency, or has treatment been recommended by a medical
professional?
Are you required to wear glasses or contact lenses for driving?
Is your visual acuity worse than 20/40 in the better eye, even with corrective lenses?
Do you have a degenerative or progressive eye condition?
Have you experienced a decrease in peripheral (side) vision?
Do you have loss or paralysis of all or part of a limb, or severe arthritis?
New or changed in the past 5 years?
Present longer than 5 years?
Do you have a condition that produces abnormal sleepiness (sleep apnea, narcolepsy, etc.)?
Are there any other health problems or use of medications which might interfere with driving ability or safety or
control of a vehicle? Please explain:______________________________________________________________
YES
YES
YES
NO
NO
NO
YES NO
YES NO
Learning &
Memory:
Mental Health
Conditions:
Answering yes to any of the above questions may result in your receiving a request for additional follow-up information.
DLD Office Use Only: Examiner Notes
UT LI
CENSE # UT ID
#
VOTER REGISTRATION
YES
NO
Do you authorize the use of information in this form for voter registration purposes?
"PRIVACY INFORMATION"
Voter registration records contain some information that is available to the public, such as your name and address, some information that is available only to government entities,
and some information that is available only to certain third parties in accordance with the requirements of law. Your driver license number, identification card number, social
security number, email address, and full date of birth are available only to government entities. Your year of birth is available to political parties, candidates for public office,
certain third parties, and their contractors, employees, and volunteers, in accordance with the requirements of law. You may request that all information on your voter
registration records be withheld from all persons other than government entities, political parties, candidates for public office, and their contractors, employees, and volunteers,
by indicating here:
Yes, I request that all information on my voter registration records be withheld from all persons other than government entities, political parties, candidates for public
office, and their contractors, employees, and volunteers.
REQUEST FOR ADDITIONAL PRIVACY INFORMATION
In addition to the protections provided above, you may request that all information on your voter registration records be withheld from all political parties, candidates for public
office, and their contractors, employees, and volunteers, by submitting a withholding request form, and any required verification, as described in the following paragraphs. A
person may request that all information on the person's voter registration records be withheld from all political parties, candidates for public office, and their contractors,
employees, and volunteers, by submitting a withholding request form with this registration record, or to the lieutenant governor or a county clerk, if the person is or is likely to be,
or resides with a person who is or is likely to be, a victim of domestic violence or dating violence.
A person may request that all information on the person's voter registration records be withheld from all political parties, candidates for public office, and their contractors,
employees, and volunteers, by submitting a withholding request form and any required verification with this registration form, or to the lieutenant governor or a county clerk, if the
person is, or resides with a person who is, a law enforcement officer, a member of the armed forces, a public figure, or protected by a protective order or a protection order.
Yes, I would like a withholding form.
Political Party:
Democratic
To register or preregister to vote in Utah, you must be a citizen of the United States, have resided in Utah for 30 days immediately before the next election, and not be a
convicted felon currently incarcerated for a felony. You must be 16 or 17 years old to preregister to vote or at least 18 years old on or before the next general election to register
to vote. If you decline to register to vote, the fact that you have declined will remain confidential and will be used only for voter registration purposes. If you register to vote, the
office with whom you register will remain confidential. The portion of your voter registration form that lists your license or identification card number, social security number,
email address, and the day of your month of birth is a private record. The portion of your voter registration form that lists your month and year of birth is a private record, the use
of which is restricted to government officials, government employees, political parties, or certain other persons. In order to be allowed to vote in a voting precinct for the first time
or to vote during the early voting period before the date of the election, you must present valid voter identification to the poll worker before voting as follows: (1) a valid form of
photo identification that shows your name, photograph, and current address; or (2) two different forms of identification that show your name and current address.
CITIZENSHIP AFFIDAVIT/VOTER DECLARATION
I hereby swear and affirm, under penalties for voting fraud set forth in Utah Code Sec. 20A-2-401 that I am a citizen of the United States and that to the best of my knowledge
and belief the information I have given is true and correct.
I do swear (or affirm), subject to penalty of law for false statements, that the information contained in this form is true, and that I am a citizen of the United States and a resident
of the State of Utah, residing at the above address. Unless I have indicated that I am preregistering to vote in a later election, I will be at least 18 years of age and will have
resided in Utah for 30 days immediately before the next election. I am not a convicted felon currently incarcerated for commission of a felony.
Independent American
_______________X_________________________________
Sign ABOVE to register to vote Date
By submitting this application, I am consenting to registration with the Selective Service System, if required by federal law. Refusal to consent to the release of information to the
Selective Service System shall result in the denial of the license and/or identification card.
Implied Consent - By operating a motor vehicle in this state you have given consent to a chemical test of your breath, blood, urine, or oral fluids for the purpose of determining if
you are operating or in actual physical control of a motor vehicle while having a blood or breath alcohol content or are under the influence of drug or a combination of both that is
prohibited by Utah law.
FAILURE TO TRUTHFULLY COMPLETE QUESTIONS MAY RESULT IN WITHDRAWAL OF DRIVING PRIVILEGE OR IDENTIFICATION CARD.
The Driver License Division may disclose the information provided on this form in accordance with Utah Code Annotated 53-3-109.
The Driver License Division may disclose the information provided on this form to an entity described in Utah Code Annotated Subsection 53-3-109(1)(b)(v).
Please visit our website dld.utah.gov for additional information.
UnaffiliatedLibertarian RepublicanConstitution United Utah
Other _______________
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UT LICENSE Visual Acuity: Passed Eye Statement (Utah DRE)

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Completed 9 June 2021

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