Dor Form 153 Possible Driver Impairment Notification
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Missouri Department of Revenue
Form
153
Possible Driver Impairment(s) Notification
This document should be completed when license office personnel observe an obvious physical impairment of an applicant, and when appropriate
restrictions are not noted on the driver license as provided in
Sections 302.173, 302.291,
and
302.301, RSMo.
Information submitted on this form may
result in a mandatory physical examination or a driver examination to determine the driving ability of the applicant.
Applicant’s Name
Driver License Number
Describe Impairment:
How long has the applicant been impaired?
r
r
r
Is the impairment permanent?
Yes
No
Unknown
_________ Years _________
Months _________ Days
Based on my observation(s) of the above named person and information relayed to me by this individual, I reasonably and in good faith, believe that he
or she cannot safely operate a motor vehicle and should be required to take a physical or a driving test to determine his or her driving ability, or what
driver license restrictions, if any, are needed.
Office Location
Address
Phone Number
(__ __ __) __ __ __-__ __ __ __
Employee Signature
Title
Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Form 153 (Revised 06-2013)
Driver License Bureau
Phone:(573) 751-2730
P.O. Box 200
Fax: (573) 522-8174
Inter-Office Box 13
E-mail: dlbmail@dor.mo.gov
Jefferson City, MO 65105-0200
Missouri Department of Revenue
Form
153
Possible Driver Impairment(s) Notification
This document should be completed when license office personnel observe an obvious physical impairment of an applicant, and when appropriate
restrictions are not noted on the driver license as provided in
Sections 302.173, 302.291,
and
302.301, RSMo.
Information submitted on this form may
result in a mandatory physical examination or a driver examination to determine the driving ability of the applicant.
Applicant’s Name
Driver License Number
Describe Impairment:
How long has the applicant been impaired?
r
r
r
Is the impairment permanent?
Yes
No
Unknown
_________ Years _________
Months _________ Days
Based on my observation(s) of the above named person and information relayed to me by this individual, I reasonably and in good faith, believe that he
or she cannot safely operate a motor vehicle and should be required to take a physical or a driving test to determine his or her driving ability, or what
driver license restrictions, if any, are needed.
Office Location
Address
Phone Number
(__ __ __) __ __ __-__ __ __ __
Employee Signature
Title
Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Form 153 (Revised 06-2013)
Driver License Bureau
Phone:(573) 751-2730
P.O. Box 200
Fax: (573) 522-8174
Inter-Office Box 13
E-mail: dlbmail@dor.mo.gov
Jefferson City, MO 65105-0200
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