Transcription of Request for Examination of Driver - Minnesota
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Request for Examination of Driver - Minnesota
PS31924-06 (01/16)R E Q U E S T F O R E X A M I N A T I O N O F D R I V E RFirst Name of DriverMiddle NameLast NameStreet AddressCityDriver's License NumberDate of BirthDate and time of incidentDRIVER INFORMATIONINCIDENT INFORMATIONL ocation of incidentWas an accident involved?YESNOWas the Driver given a citation?YESNOC heck one or more of the following that apply and describe in the summary section below:General physical/health problemDiabetic loss of consciousness or voluntary controlVision problemLack of physical driving skillsViolation of "ANY USE OF ALCOHOL/DRUG INVALIDATES LICENSE" restriction(please attach report verifying alcohol/drug use)Mental or emotional problem (including road rage, memory loss, etc.)
of this driver under Minnesota Statute 171.13. Date Phone Number City Title or Relationship to Driver Law Enforcement Agency or Printed Name of Person Reporting Signature of Officer or Person Reporting Badge Number (if applicable) MINNESOTA DEPARTMENT OF PUBLIC SAFETY . DRIVER AND VEHICLE SERVICES. DRIVER EVALUATION UNIT 445 …
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