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Vision Examination For Out Of State Driver License Applicants BMV 2407 - Ohio

Vision Examination For Out Of State Driver License Applicants Form. This is a Ohio form and can be used in Driver License Bureau Of Motor Vehicles Statewide .
 Fillable pdf Last Modified 4/17/2014
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OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES VISION EXAMINATION FOR OUT-OF-STATE DRIVER LICENSE APPLICANTS In accordance with Ohio Revised Code (R.C.) 4507.12, all applicants renewing their Ohio driver license are required to submit to a vision screening procedure. No license shall be issued to any person until the person's vision is corrected to meet the vision screening required by this section. APPLICANT - This form must be returned with your application for renewal of your Ohio driver license. Also, results must be submitted in the English language or it will be returned. OHIO DRIVER LICENSE # APPLICANT LAST NAME OHIO RESIDENCE ADDRESS DATE OF BIRTH SEX HEIGHT SOCIAL SECURITY # APPLICANT FIRST NAME CITY WEIGHT HAIR DATE MI ZIP CODE EYES I, , hereby authorize a licensed optometrist or ophthalmologist, to examine me and provide the following information regarding my visual condition to the Ohio Bureau of Motor Vehicles. X APPLICANT SIGNATURE DATE OPHTHALMOLOGIST/OPTOMETRIST - Please conduct these examinations and return this form to the applicant. ALL SECTIONS (INCLUDING HORIZONTAL FIELDS) MUST BE COMPLETED. ALL RESULTS MUST BE SUBMITTED IN THE ENGLISH LANGUAGE OR IT WILL BE RETURNED. ACUITY Right Without Lenses With Present Lenses With New Lenses 20/ Left 20/ Both Nasal 20/ Temporal 20/ 20/ 20/ HORIZONTAL FIELD (DEGREES ONLY) Right Left ° ° ° ° The Horizontal Field refers to the angular extent of absolute limit of vision (in degrees) for nasal and temporal from fixation for each eye as measured with a large perimetry target. 20/ 20/ 20/ Except for normal deterioration due to aging, does the applicant have a progressive visual deficiency? If "YES", please describe condition. YES NO Due to this condition, is it necessary for the Ohio Bureau of Motor Vehicles to receive periodic vision exams? YES NO CERTIFICATION - The information that I have provided is based upon my examination of the person named hereon and to the best of my knowledge is true and correct. NAME OF OPHTHALMOLOGIST / OPTOMETRIST ADDRESS COUNTY SIGNATURE OF OPHTHALMOLOGIST/OPTOMETRIST CITY TELEPHONE # EXAMINATION DATE LICENSE # / REGISTRATION # STATE / PROVINCE ZIP CODE X BUREAU USE ONLY RESTRICTED TO: A B G NONE CORRECTIVE LENSES DAYLIGHT DRIVING ONLY F1 F2 L OUTSIDE & INSIDE MIRRORS RT OUTSIDE & INSIDE MIRRORS BMV 2407 10/13 [760-1175] American LegalNet, Inc. www.FormsWorkFlow.com
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