Form 5294 - Physician'S Statement - Permanent Disability Indicator
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Missouri Department of Revenue
5294
Physician’s Statement - Permanent Disability Indicator
Attention: physician, physical therapist, occupational therapist licensed pursuant to
Chapter 334, RSMo,
or other authorized
licensed health care practitioner.
This form must be completed in full and submitted by applicants to meet Department of Revenue requirements to obtain
a permanent disability indicator on their driver license or nondriver license. Please complete this form in full. A stamped
signature is not acceptable. The issuance of a permanent disability indicator on a driver or nondriver license is not for
the purpose of any determination of eligibility for any public benefit.
Last Name
First Name
Middle
Date of Birth (MM/DD/YYYY)
Driver License Number
___ ___ / ___ ___ / ___ ___ ___ ___
Address
City
State
Zip Code
Printed Last Name
First Name
Middle
Telephone Number
(
)
-
___ ___ ___
___ ___ ___
___ ___ ___ ___
Address
City
State
Zip Code
Personal signature required of physician, physical therapist, occupational therapist licensed pursuant to
Chapter 334,
RSMo, or other authorized licensed health care practitioner.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and
correct. I certify that I have examined the above named patient and have determined him or her to have a physical
or mental impairment, which substantially limits his or her ability to perform one or more major life activities and is
permanent in nature.
Signature
Printed Name
Registration Number
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Mail to:
Form 5294 (Revised 05-2013)
Driver License Bureau
Phone: (573) 751-2730
Visit dor.mo.gov/drivers/
P.O. Box 200
E-mail: dlbmail@dor.mo.gov
for additional information.
Jefferson City, MO 65105-0200
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