Vision Statement Template - South Dakota Department Of Public Safety Driver Licensing Program
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1SOUTH DAKOTA DEPARTMENT OF
PUBLIC SAFETY
DRIVER LICENSING PROGRAM
VISION STATEMENT
Name of Applicant ________________________________________ DL# ______________________
Address _________________________________________________ BIRTHDATE ________________
Permission is hereby granted for the release of the medical data below and other medical history applicable in my case to the South
Dakota Department of Public Safety, Driver Licensing Program.
I declare and affirm under the penalties of perjury that this application has been examined by me, and to the best of my knowledge and
belief, is in all things true and correct. Any false statement or concealment of any material facts subjects any license issued to
immediate cancellation.
Applicant Signature ___________________________________________________ Date _____________________________
EYE EXAMINATION: This portion must be completed by a licensed optometrist or ophthalmologist:
(leave no blanks)
Please answer all questions
.
DISTANCE VISUAL ACUITY:
Both Eyes Together
Right Eye
Left Eye
Without Lenses
20/
20/
20/
With Present Lenses
20/
20/
20/
With Best Possible RX
20/
20/
20/
1. For best possible distance visual acuity have corrective lenses been prescribed and dispensed? ______________
2. Is there any difficulty seeing in dim light or at night? _______________________
3. Does patient have any other visual deficiency which, to your knowledge, would prevent him/her from safely
operating a motor vehicle? Yes_______________ No_______________. If yes, please explain
______________________________________________________________________________________
4. Recommendation as to frequency of visual re-examination: 1 YR ______ 2 YR ______ 3 YR _______
5. Doctor’s opinion regarding applicant’s visual ability to drive safely:
a. Without restrictions ________ b. With restrictions __________ c. Inadequate _______________
Recommended restrictions (check all that apply below):
Corrective Lenses _______
Left Outside Rearview Mirror ________
50 Mile Radius of Residence ________ No Driving Outside City Limits _________
Daylight Only _________
Other ___________
Being a licensed optometrist or ophthalmologist, I certify that I have personally examined the eyes of the applicant named
and a true record of this examination appears above.
Doctor’s Name (Please Print Legibly) ______________________________________________________________
Doctor’s Address (Please Print Legibly) ____________________________________________________________
Doctor’s Phone Number _____________________________________
Doctor’s Signature _____________________________________________
Date _______________________
Return completed application to: Department of Public Safety, Driver Licensing Office, 118 W. Capitol Avenue, Pierre
SD 57501 or fax to (605) 773-3018.
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