Form Dmv 06-105 - Clp And Cdl Data Form Page 2
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2(Continued on back side)
__No
B. experienced vertigo or multiple episodes of dizziness or fainting ................................................................................
__Yes
C. disorientation .................................................................................................................................................................
__Yes
__No
D. seizures (date:
) ...................................................................................................................
__Yes
__No
E. impairment of memory, memory loss ...........................................................................................................................
__Yes
__No
6.
Do you experience any condition which affects your ability to operate a motor vehicle due to loss or impairment of:
A. foot/leg ..........................................................................................................................................................................
__Yes
__No
B. upper body strength .......................................................................................................................................................
__Yes
__No
C. range of motion/mobility...............................................................................................................................................
__Yes
__No
D. hand/arm .......................................................................................................................................................................
__Yes
__No
E. neurological/neuromuscular disease .............................................................................................................................
__Yes
__No
7.
Since the issuance of your last license/permit, has your health or medical condition worsened? .......................................
__Yes
__No
To the best of my knowledge and belief, I declare under penalty of election falsification that: 1) I live in the State of Nebraska at the address
provided in this application; 2) I have not been convicted of a felony or, if convicted, it has been at least two years since I completed sentence
for the felony, including any parole term; 3) I have not been officially found to be non compos mentis (mentally incompetent); and 4) I am a
citizen of the United States. Any registrant who signs this application knowing that any of the information in the application is false shall be
guilty of a Class IV felony under section 32-1502 of the statutes of Nebraska. The penalty for a Class IV felony is up to two years
imprisonment and twelve months post-release supervision, a fine of up to ten thousand dollars, or both.
By signing this document, I swear or affirm that the answers I provided as part of this application process are true. I understand and
acknowledge that use of a false or fictitious name, knowingly making a false statement, or knowingly concealing a material fact in this
application can result in a fine, imprisonment, or both, and the revocation of my permit or license. I hereby attest that my United States
citizenship or qualified alien response and the information provided in this application and any related application for public benefits are true,
complete and accurate and I understand that this information may be used to verify my lawful presence in the United States.
________________________________________________________________________________
__________________________________________
Applicant’s Signature
Date
DMV 06-105 8/2017
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