Form Ds 699a - Self Referral For Reevaluation Of Driving Skill

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STATE OF CALIFORNIA
®
DEPARTMENT OF MOTOR VEHICLES
A Public Service Agency
SELF REFERRAL FOR
REEVALUATION OF DRIVING SKILL
InstructIons:
1. Please complete this form if you wish the Department of Motor Vehicles (DMV) to reevaluate your
ability to drive safely.
PLEASE NOTE: Submission of this form to DMV initiates a reexamination of your licensing
qualifications and may result in action taken against your driving privilege. DMV will contact you and
you may be required to take a vision, written, and/or driving test. DMV may also request medical
history information from you and your physician.
2. After completing this form, you may submit it to any DMV office, including the same office where you
received it. You may also mail or fax it to a Driver Safety Office. See reverse for the address of the
Driver Safety Office nearest your home.
YOUR NAME
YOUR DRIVER LICENSE NUMBER
YOUR BIRTH DATE
TELEPHONE NUMBER
(
)
YOUR ADDRESS
CITY
STATE
ZIP CODE
(oPtIonAL) I AM REQUESTING THIS REEVALUATION BECAUSE:
YOUR SIGNATURE
TODAY’S DATE
X
DS 699 A (REV. 12/2014) WWW
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