DMV APPLICATION FOR DRIVING PRIVILEGES OR …

1 LAST NAME (PRINT NAME) CLASS CINSTRUCTION PERMITDRIVER LICENSEENDORSEMENTID F XDo you want your license or ID card to showthat you are an anatomical donor? S PLACE OF BIRTH (CITY & STATE OR COUNTRY)MOTHER'S MAIDEN NAMEFIRST NAMEDRIVER / ID NUMBER RESTRICTIONSHEIGHTWEIGHTSEX(CIRCLE)EYE COLORHAIR COLORRESIDENCE ADDRESSCITY, STATE, ZIP CODEMAILING ADDRESS (IF DIFFERENT FROM RESIDENCE ADDRESS)CITY, STATE, ZIP CODENOYESAPPLICATION FOR DRIVING PRIVILEGES OR ID CARD 735-173 (1-18)DATE STAMPSTK# 300093 TSR IDYou are required to report any mental or physical condition or impairment that affects your ability to drive safely. You are not required to report all your health conditions only those that affect your ability to drive safely. DMV will use your answers to the following questions only for the purpose of determining your eligibility for an Oregon DRIVING privilege.

2 If you have a condition or impairment that makes you unable to safely operate a motor vehicle, you are not eligible for a DRIVING privilege until you have provided additional medical information and/or passed DMV tests. If you answer Yes to any one of the questions below, we will not be able to issue you a license at this Do you have any physical or mental conditions or impairments that affect your ability to drive safely?*IfYes: a) What is the condition or impairment?: _____Describe how this affects your ability to drive safely: _____3. Do you use alcohol, inhalants, or controlled substances to a degree that affects your ability to drive safely?* If Yes: Describe how your use affects your ability to drive safely: _____BB_____YESNOYES*NODATEYES*NODRIVE TEST STOP - DO NOT WRITE IN THE AREA BELOW - FOR DMV OFFICE USE ONLYTSR IDDATEVISION:HEARING:DEAFGOODOK W/BIOPTIC LENSESOK/WCLOKOUTSTANDING REQUIREMENTSDATE RECEIVEDTSR IDVISION / HEARINGDATE STAMPTESTTESTTESTSCORESCORESCORETSR IDTSR IDTSR IDDATE STAMPDATE STAMPKNOWLEDGE TEST2 DATECLASSSCORETSR ID3 DATECLASSSCORETSR ID1 DATECLASSSCORETSR IDXDOCUMENTS PRESENTEDDATEDATE2nd CHECKTSR ID2nd CHECKTSR ID2nd CHECKTSR ID$FEEDATE OF BIRTH (M-D-Y)US BIRTH CERTIFICATE/PASSPORT/PASSPORT CARD FOREIGN PASSPORT & DHS DOC.

3 Or ADMIT. STAMP DHS DOCUMENTOTHER (Specify) _____LP=C LP=P LP=F LP=UCURRENT OR PREVIOUS MILITARY SERVICE: By checking this box I authorize DMV to send my name and address to the Oregon Department of Veterans' Affairs (ODVA) for the purpose of receiving benefit :DOCUMENTS PRESENTEDUS BIRTH CERTIFICATE/PASSPORT/PASSPORT CARD FOREIGN PASSPORT & DHS DOC. or ADMIT. STAMP DHS DOCUMENTOTHER (Specify) _____LP=C LP=P LP=F LP=UDOCUMENTS PRESENTEDUS BIRTH CERTIFICATE/PASSPORT/PASSPORT CARD FOREIGN PASSPORT & DHS DOC. or ADMIT. STAMP DHS DOCUMENTOTHER (Specify) _____LP=C LP=O LP=F LP=UBy signing this APPLICATION , I certify that all documentation and information I provided to DMV is true and correct. I understand it is a crime to knowingly make a false APPLICATION for DRIVING PRIVILEGES or ID card. The offense is a class A misdemeanor and is punishable by jail time, a fine or both.

4 DMV will cancel and/or suspend my permit , driver license or ID if I make a false statement or present false OF APPLICANTSSN:Disclosure of your Social Security number (SSN) is mandatory for issuance, renewal or replacement of your driver license or identification card under ORS (1).IF under18 years of age:I am a resident of or domiciled in Oregon as described in And applying for first DRIVING privilege, applicant meets school enrollment requirements under ORS or has a diploma or GED (proof of diploma or GED required). And applying for first Class C license , applicant has completed DRIVING experience requirements under ORS (1)(2): 50 hours and Driver Education or 100 hours, or has a valid license from another state. Signature of applicant s mother or father whose parental rights have not been terminated or legal C RESTR'DLP or ADDRESSREIN. FEE/SR-22 OTHER:NOTE:FARMMIDDLE NAMESOCIAL SECURITY NUMBER9 RWHU UHJLVWUDWLRQ IRUPV DUH DYDLODEOH DW WKH '09 RIILFH ,I \RX ZRXOG OLNH WR UHJLVWHU WR YRWH WRGD\ SOHDVH DVN D '09 FOHUN DM you ever had a driver license from another state, territory, or country?

5 YES INFORMATION:NOTE: YOUR ADDRESS BELOW MUST BE CURRENT. THE POSTAL SERVCIE WILL NOT FORWARD YOUR license OR ID NUMBER( )APPLICANT CERTIFICATION:MEDICAL FITNESS: Skip this section if applying for an Identification Is your driver license currently suspended, cancelled or revoked?If yes, what state or country: _____ Number (if known): _____List other names you have used on a driver license or ID card. 1. _____ 2. _____NO YES NOG DAYLIGHTACUITY ONLYF OUTSIDEMIRRORA. LEFT TURNAPPROACHIF STOPTURNINGCOMPLETE TURNA. RIGHT TESTSCORE SHEETREPRESENTATIVEINSURANCE COMPANYPOLICY NUMBEREXPIRATION DATEGFIFs Grounds for Immediate Failure1. An accident involving any amount of property damage or personal The applicant refuses to perform any maneuver which is part of the prescribed DRIVING Any dangerous action in which:4. The applicant commits any of the following:5. If after proceeding a short distance on the drive test or after completion of the drive test itbecomes apparent that the applicant is dangerously inexperienced or is unable to operatevehicle equipment, score the test "G5.

6 "a. An accident is prevented by expert DRIVING or action on the part of other The examiner is forced to assist the driver in avoiding an accident physically or The applicant drives or backs over curb or The applicant creates a serious traffic hazard by stalling or other improper DRIVING Passes another car which is stopped at a crosswalk, yielding to a pedestrian or passes aschool bus stopped with its red lights Makes or starts to make a turn into or from the wrong lane under traffic conditions thatrender such actions Runs through or has to be stopped from running one red light or one stop CHANGELEFTB. POSTED Stop5. Intersection, Crosswalk, Too or Observation1. Attention3. Stop - too suddenly, full,unnecessary4. Attention1. Speed3. Attention1. Too Fast1. PedestriansSCORE7. Following6. Speed5. Lane Usage4. Strays from DRIVING /Reaction to Emergency3. Vehicle Control2.

7 Fails to Anticipate2. Too Slow2. Position2. Stop - too close,crosswalk, intersection1. Signal3. Position2. Observation2. Path1. Observation2. of OF ATTENTION Non SPACETOTAL ERRORS1 = 972 = 94 3 = 914 = 885 = 856 = 827 = 798 = 769 = 7311 = 6712 = 6413 = 6110 = 70 DATECOURSEAPPLICANT'S NAMEODL #EQUIPMENT FAIL:RESTRICTIONPLATE/TEMP31232 ONOFFONOFF1