California > Statewide > Administrative Hearings And Reexaminations
Request For Driver Examination DS-699 - California
| Request For Driver Examination Form. This is a California form and can be used in Administrative Hearings And Reexaminations Statewide . |
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STATE OF CALIFORNIA DEPARTMENT OF MOTOR VEHICLES ® A Public Service Agency REQUEST FOR DRIVER REEXAMINATION INSTRUCTIONS: 1. Complete this form if you wish the Department of Motor Vehicles (DMV) to reevaluate a driver's ability to drive safely. 2. Sign this request in the signature block provided. You may request that your name not be revealed to the individual being reported. Confidentiality will be honored to the fullest extent possible. 3. Take your completed request to any DMV office or mail to: DMV, Driver Safety Office (see addresses below for your local office.) Note: All fields marked with an asterisk (*) are required. NAME OF PERSON BEING REPORTED (FIRST, M.I., LAST) * DATE OF BIRTH OR APPROXIMATE AGE * TELEPHONE NUMBER ( STATE ) ZIP CODE DRIVER LICENSE NUMBER VEHICLE LICENSE PLATE NUMBER, IF AVAILABLE STREET ADDRESS * CITY * * * DRIVER CONDITION--Check all appropriate boxes below. Please use the space below to provide specific details, if known, about the driver's medical (physical or mental) condition such as name of disease or illness, any medications taken, etc. Medical Condition Confused/Disoriented Physical Condition Alcohol/Drug Use (Describe below) Mental/Emotional Condition Blackouts, Seizures, Fainting Spells Vision Condition Needs help with daily activities (i.e., cooking, dressing, bathing, balancing checkbook) Weakness or Coordination Problems Other: Difficulty Walking DRIVER BEHAVIOR--Check appropriate boxes for driving problems you have observed: (Use space below if needed for additional comments.) Does not see or react to other cars, pedestrians, etc. Turns in front of on-coming cars Drives in wrong lane Allows car to drift in and out of lane Drives on wrong side of the road Backs up or changes lanes without looking back or checking mirrors Acts violent or aggressive when driving Applies brake and gas pedals at the same time Drives too slow, or stops, for no reason Slow reactions that may be caused by medications or drugs Has trouble steering, braking, or otherwise controlling car Drives on sidewalk Is confused by traffic Makes driving mistakes while talking to passengers Gets lost or confused while driving near home Falls asleep while driving Fails to react to traffic signals, other cars, pedestrians, etc. Other actions (Describe below) Makes turns from wrong lane You may use the space below to further describe the driver's condition(s) or action(s) which lead you to believe this driver should be reevaluated by DMV. DS 699 (REV. 8/2012) WWW American LegalNet, Inc. www.FormsWorkFlow.com YOUR RELATIONSHIP TO DRIVER: * Relative: Friend Caregiver Vision Specialist Court/Code Other: Check here if you would like to have your name kept confidential. Confidentiality will be honored to the fullest extent possible. Unsigned reports will not be considered. DAYTIME TELEPHONE NUMBER NAME (Please print)* ( YOUR MAILING ADDRESS (City, State, Zip Code) ) * * DATE SIGNATURE * X YOU MAY MAIL OR TAKE THIS COMPLETED FORM TO YOUR LOCAL DRIVER SAFETY OFFICE AT ONE OF THESE LOCATIONS: Bakersfield, 5800 District Blvd., Ste. 100-B, Bakersfield, 93313 City of Commerce, 5801 E. Slauson Ave., Ste. 250 City of Commerce, 90040-3050 City of Orange, 790 The City Drive, Ste. 420 City of Orange, 92868-4941 Covina, 1365 N. Grand Ave., Ste. 101, Covina, 91724 El Segundo, 390 N. Sepulveda Blvd. Ste. 2075, El Segundo, 90245-4470 Fresno, 2510 S. East Ave., Ste. 310, Fresno, 93706-5112 Oakland, 7677 Oakport St., Ste. 220, Oakland, 94621-1906 DS 699 (REV. 8/2012) WWW Oxnard, 2051 N. Solar Dr., Ste. 100, Oxnard, 93036 Redding, 2650 Churn Creek Rd., Ste. 200, Redding, 96002-1169 Sacramento, 4700 Broadway, 2nd Flr., Sacramento, 95820-1501 San Bernardino, 1845 Business Center Dr., Ste 212, San Bernardino, 92408-3447 San Diego, 9174 Sky Park Court, Ste. 200, San Diego, 92123-2666 San Francisco, 1377 Fell St., 2nd Floor, San Francisco, 94117-2296 San Jose, 90 Great Oaks Blvd., Ste. 104, San Jose, 95119 Van Nuys, 6150 Van Nuys Blvd., Ste. 205, Van Nuys, 91401-3333 American LegalNet, Inc. www.FormsWorkFlow.com
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