Driver License Medical Self-Declaration

Full Name

First NameLast Name

Date of Birth

Date

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Residential Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Do you currently have, or have you ever been diagnosed with, any of the following medical conditions? (Select all that apply)

Other

Are you currently taking any medication that may affect your ability to drive safely?

If you answered "Yes" to taking medication, please list the medications and any side effects you experience. If not applicable, type "N/A".

Do you use any assistive devices for driving (e.g., glasses, hearing aids, prosthetics)?

Have you experienced any loss of consciousness or blackouts in the past 12 months?

Signature (Please sign to confirm your declaration)