Vision Statement Form - 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: _________________________________________________ Birth Date: ________________
Phone Number: _____________________________________Email Address: ___________________________
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:
Please answer all questions (leave no blanks).
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?
______________
2.
Have the corrective lenses been dispensed?
______________
3.
Is there any difficulty seeing in dim light or at night?
_________________
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 ___________
Doctor’s opinion regarding applicant’s visual ability to drive safely:
Does patient have any other visual deficiency which, to your knowledge, would prevent him/her from safely operating a motor
vehicle? Yes: (INADEQUATE VISION) ________ No: __________ If yes, please explain_______________________
___________________________________________________________________________________________________
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 must complete all info below.
Doctor’s Name (Please Print Legibly) ______________________________________________________________
Doctor’s Address (Please Print Legibly) ____________________________________________________________
Doctor’s Phone Number _____________________________________Fax Number__________________________
(Vision Statements are honored for 6 months from the exam)
Date of Exam
________________________________
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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