Form Dmv-204 - Application For Nevada Driver'S License By Mail Page 2
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1
2Full Name (Last, First, Middle)
__
ALL APPLICANTS COMPLETE THIS SECTION
Have you suffered from or are you under a doctor’s care for any of the following since your last license was issued?
Yes
No
Loss or impairment of a limb
Yes
No
Mental or emotional disorder
Yes
No
Epilepsy or seizures
Yes
No
Fainting or dizzy spells
If the answer is “YES” to any of the above, please explain the nature of the condition and date(s) of occurrence:
_________________________________________________________________________________________________
Yes
No
Do you have a disability that would prevent you from driving safely?
Yes
No
Are you taking any medication that affects your ability to drive safely?
Yes
No
Have you ever had your driving privilege revoked, suspended, canceled, or denied?
If “YES,” When?_______________________ Where? _____________________________________________
Why? ___________________________________________ Class/Type? _____________________
RENEWAL APPLICANTS MUST ALSO HAVE THIS SECTION COMPLETED
Certificate of Vision Examination
This section must be completed for every person applying to renew a Nevada driver’s license. You may have this report completed by a
licensed physician, ophthalmologist, optician, optometrist, or driver’s license issuing agency in your area. The form must be dated within the
past 90 days and signed by the person who administered the exam. It also needs to show separate visual acuity readings for the right, left
and both eyes, and indicate whether the exam was taken with or without corrective lenses. A prescription for corrective lenses cannot be
accepted in lieu of the required vision examination.
Vision
Without Corrective Lenses
With Corrective Lenses
Right Eye...................................................................... 20/
20/
Left Eye ........................................................................ 20/
20/
Both Eyes ..................................................................... 20/
20/
Does this person have a progressive disease or condition of the eye?
Yes
No
_______________________________________________________
_______________________________________
Signature: Driver’s License Issuing Agency/Physician/Optometrist
Date of Examination (must be within the last 90 days)
_______________________________________________________
(
) ________________________________
PRINTED Name: Issuing Agency/Physician/Optometrist
Area Code and Phone Number
___________________________________________________________________________________________________
PRINTED Office Address: Issuing Agency/Physician/Optometrist
RENEWAL APPLICANTS 71 OR OLDER MUST ALSO HAVE THIS SECTION COMPLETED
Physical Evaluation
All renewal applicants who will be 71 years of age or older on their driver’s license expiration date must have this report completed,
90
signed, and dated by a licensed physician no more than
days before it is submitted to the Nevada DMV.
Does a medical condition exist that would prevent this patient from safely operating a motor vehicle? .........
Yes
No
If “Yes,” please explain: __________________________________________________________________________
Is this patient taking any medication that would negatively affect his/her ability to drive safely?....................
Yes
No
If “Yes,” please explain: __________________________________________________________________________
_________________________________
____________________
_________________________________
Physician’s Signature
Phy
sician’s License Number
Date of Physical Evaluation
(must
be within the last 90 days)
_______________________________________________________
(
) __________________________
PRINTED Name of Physician
Area Code and Phone Number
___________________________________________________________________________________________________
PRINTED Office Address of Physician
DMV-204 (Revised 2/2010 - Previously DLD-4)
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