Form 4317 - Vwp License Application - Missouri Department Of Revenue Page 2

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VISION EXAMINATION RECORD

An eye doctor or physician must complete the following information:

Acuity - Your vision acuity reading must be recorded for each eye and then a combined acuity for both eyes, i.e., 20/20.

Field - The complete peripheral reading for each eye and a combined reading must be shown in degrees (numerics)

i.e., 55 . Do not record reading such as "FULL" or "NORMAL".

20/40 IN EITHER OR BOTH EYES IS THE MINIMUM STANDARD FOR A MISSOURI LICENSE.

DISTANT VISION ONLY

RIGHT

LEFT

BOTH

ARE CORRECTIVE LENSES BEING FITTED TO REACH BEST

POSSIBLE CORRECTION?

YES

20/

WITH PRESENT CORRECTION

20/

20/41 - 20/59 REQUIRES A DAYLIGHT DRIVING RESTRICTION.

20/

SHOULD THIS RESTRICTION BE REMOVED?

WITHOUT CORRECTION

20/

YES

20/

BEST POSSIBLE CORRECTION

20/

20/60 - 20/74 REQUIRES A 45 MPH RESTRICTION. SHOULD

THIS RESTRICTION BE REMOVED?

FIELD

YES

NOTE: SPECIAL RESTRICTIONS CAN BE ADDED IF REQUIRED DUE TO VISUAL CONDITION. SPECIFY ADDITIONAL RESTRICTION(S) BELOW.

EYE DOCTOR / PHYSICIAN'S SIGNATURE

DATE

ADDRESS

TELEPHONE NUMBER

(

)

CITY

STATE

ZIP CODE

REGISTRATION NUMBER

SOCIAL SECURITY OBJECTOR INFORMATION

Complete the following only if you wish to object to the use of your Social Security Number as your driver's license

number. You must disclose your Social Security Number, even if you object.

NOTE: If you are a Class A, B or C applicant, you may object only for religious reasons and must also submit

documentation of your religious beliefs.

MY SOCIAL SECURITY NUMBER IS (INCLUDE VERIFICATION OF SSN)

I object to using my Social Security Number as my driver's license number.

RESTRICTION OF INFORMATION

All driver's/nondriver's license records are considered public records; however, effective September 13, 1997, you may protect the personal information

on your driver's license records from release for public use or bulk mailing by indicating "yes" below, or by completing form DOR-4673 Restriction of

Personal Information.

YES

Withhold my driver's/nondriver's personal information from purchase or release for public use or bulk mailing except as provided by law.

SIGNATURE

DATE

MO 860-2508 (12-97)

DOR-4317 (12-97)