Form MV-312 "Report of Visual Status by an Optometrist or Ophthalmologist" - Delaware

What Is Form MV-312?

This is a legal form that was released by the Delaware Department of Transportation - Division of Motor Vehicles - a government authority operating within Delaware. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

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Download a fillable version of Form MV-312 by clicking the link below or browse more documents and templates provided by the Delaware Department of Transportation - Division of Motor Vehicles.

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Download Form MV-312 "Report of Visual Status by an Optometrist or Ophthalmologist" - Delaware

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STATE OF DELAWARE – DIVISION OF MOTOR VEHICLES
REPORT OF VISUAL STATUS BY AN OPTOMETRIST OR OPHTHALMOLOGIST
NAME OF APPLICANT____________________________________________________________D.O.B.____________________D.L.#_____________________
ADDRESS__________________________________________________________________________________________________DATE____________________
DIVISION LOCATION________________________________________________________________________________________________________________
VISUAL
IS THERE ANY EVIDENCE OF EYE DISEASE OR DEFECTOF STRUCTURE
ACUITY
NO R/
WITH R/
THAT WOULD AFFECT VISUAL PERFORMANCE NOW OR IN THE FUTURE?
R.E.
20/
20/
CONTACT LENS
L.E.
20/
20/
GLASSES
B.E.
20/
20/
WOULD DRIVER’S VISUAL ABILITIES BE
IMPROVED BY CORRECTIVE LENS?_____________________________
IN THE CAUSE OF SAFETY, ARE THERE ANY RESTIRCTIONS THAT
ARE THEY BEING PRESCRIBED?________________________________
SHOULD BE IMPOSED ON THE LICNESE?
NO
YES
DESCRIBE ANY FIELD DEFECT:
CORRECTIVE LENSES
DAYLIGHT DRIVING ONLY
MV-312
Doc. No. 45-07-95-09-01
WITH REGARD TO DRIVING, HOW OFTEN SHOULD APPLICANT HAVE VISION
I HEREBY CERTIFY THAT I’M LICENSED TO PRACTICE
CHECKED?
______________________________________________________ IN THE STATE OF
1 YR.
2 YR.
3 YR.
4 YR.
ARE THERE ANY CIRCUMSTANCES THAT MIGHT BE EXPLAINED TO AID
_____________________________________LIC OR REC. NO.__________________
FINAL DISPOSITION OF THIS CASE?
______________________________________________________________________
REMARKS:
NAME AND DEGREE – PLEASE PRINT
______________________________________________________________________
ADDRESS
______________________________________________________________________
SIGNATURE
DATE
PRESCRIPTION BLANK OR STATEMENT OF EXAMINING DOCTOR MUST
BE INCLUDED WITH THIS REPORT. MAIL TO EXAMINER AT HIS LOCATION.
(DO NOT RETURN TO APPLICANT)
20/40 -UNRESTRICTED
20/50 - DAYLIGHT DRIVING ONLY
BELOW 20/50 – LICENSE DENIED
STATE OF DELAWARE – DIVISION OF MOTOR VEHICLES
REPORT OF VISUAL STATUS BY AN OPTOMETRIST OR OPHTHALMOLOGIST
NAME OF APPLICANT____________________________________________________________D.O.B.____________________D.L.#_____________________
ADDRESS__________________________________________________________________________________________________DATE____________________
DIVISION LOCATION________________________________________________________________________________________________________________
VISUAL
IS THERE ANY EVIDENCE OF EYE DISEASE OR DEFECTOF STRUCTURE
ACUITY
NO R/
WITH R/
THAT WOULD AFFECT VISUAL PERFORMANCE NOW OR IN THE FUTURE?
R.E.
20/
20/
CONTACT LENS
L.E.
20/
20/
GLASSES
B.E.
20/
20/
WOULD DRIVER’S VISUAL ABILITIES BE
IMPROVED BY CORRECTIVE LENS?_____________________________
IN THE CAUSE OF SAFETY, ARE THERE ANY RESTIRCTIONS THAT
ARE THEY BEING PRESCRIBED?________________________________
SHOULD BE IMPOSED ON THE LICNESE?
NO
YES
DESCRIBE ANY FIELD DEFECT:
CORRECTIVE LENSES
DAYLIGHT DRIVING ONLY
MV-312
Doc. No. 45-07-95-09-01
WITH REGARD TO DRIVING, HOW OFTEN SHOULD APPLICANT HAVE VISION
I HEREBY CERTIFY THAT I’M LICENSED TO PRACTICE
CHECKED?
______________________________________________________ IN THE STATE OF
1 YR.
2 YR.
3 YR.
4 YR.
ARE THERE ANY CIRCUMSTANCES THAT MIGHT BE EXPLAINED TO AID
_____________________________________LIC OR REC. NO.__________________
FINAL DISPOSITION OF THIS CASE?
______________________________________________________________________
REMARKS:
NAME AND DEGREE – PLEASE PRINT
______________________________________________________________________
ADDRESS
______________________________________________________________________
SIGNATURE
DATE
PRESCRIPTION BLANK OR STATEMENT OF EXAMINING DOCTOR MUST
BE INCLUDED WITH THIS REPORT. MAIL TO EXAMINER AT HIS LOCATION.
(DO NOT RETURN TO APPLICANT)
20/40 -UNRESTRICTED
20/50 - DAYLIGHT DRIVING ONLY
BELOW 20/50 – LICENSE DENIED