Department of Motor Vehicles Health Waiver Form

Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Phone Number

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

Email Address

example@example.com

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Describe your health condition or limitation affecting DMV services

Is this condition temporary or ongoing?

Other

Which mobility limitations apply?

Which vision, hearing, or speech limitations apply?

List medications that may affect your visit

Do you need special assistance or accommodations?

DMV service needed

Reason health waiver is being requested

Preferred visit method or service setting

Requested accommodations

Scheduling constraints due to health condition

Date

Hour MinutesAM/PM Option

Applicant Signature

Date of Submission

Date