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COMMERCIAL DRIVER LICENSE APPLICATION
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Do you now have, or have you ever had, an instruction permit, identification card,
commercial driver license or driver license from Oregon issued in your name or any
other name or other Oregon driver license number?
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You 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 license. If you have a
condition or impairment that makes you unable to safely operate a motor vehicle, you are not eligible for a license 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 time.
YES
NO
1) Do you have a vision condition or impairment that has not been corrected by glasses, contacts or surgery that affects your ability to drive safely?
NO
YES*
2) Do you have any physical or mental conditions or impairments that affect your ability to drive safely?
*If Yes: a) What is the condition or impairment?: _______________________________________________________________________________________________
b) Describe how this affects your ability to drive safely: ___________________________________________________________________________________
YES*
NO
3) Do you use alcohol, inhalants, or controlled substances to a degree that affects your ability to drive safely?
*If Yes: a) Describe how your use affects your ability to drive safely: _______________________________________________________________________________
"YSIGNINGTHISAPPLICATION)CERTIFYTHATALLDOCUMENTATIONANDINFORMATION)PROVIDEDTO$-6ISTRUEANDCORRECT)UNDERSTANDITISACRIMETOKNOWINGLYMAKEAFALSEAPPLICATIONFOR
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SIGNATURE OF APPLICANT
X
SSN:'isclosure of your Social Security number (SSN) is mandatory for issuance, renewal or replacement of your driver license or identification card under ORS 807.021(1)DQG&)5.
STOP - DO NOT WRITE IN THE AREA BELOW - FOR DMV OFFICE USE ONLY
OUTSTANDING REQUIREMENTS
X
X
DATE RECEIVED
LP, SSN + ADDRESS
REIN. FEE/SR-22
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VISION:
REFERRED:
PROOF OF LEGAL PRESENCE:
US CITIZEN
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TSR ID
MEDICAL CERTIFICATION EXPIRATION DATE
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DATE
DATE STAMP
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PROOF OF LEGAL PRESENCE:
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3522) PRESENTED
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TSR ID
2nd APPROVAL
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