Form DLD23A "Request for Re-evaluation" - Nevada

What Is Form DLD23A?

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

Form Details:

  • Released on September 1, 2005;
  • The latest edition provided by the Nevada Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DLD23A by clicking the link below or browse more documents and templates provided by the Nevada Department of Motor Vehicles.

ADVERTISEMENT
ADVERTISEMENT

Download Form DLD23A "Request for Re-evaluation" - Nevada

Download PDF

Fill PDF online

Rate (4.8 / 5) 88 votes
555 Wright Way
Carson City, NV 89711
Reno/Sparks/Carson City (775)
684-4DMV (4368)
Rural Nevada (877) 368-7828
Fax: (775) 684-4829
Website:
www.dmvnv.com
Request for Re-Evaluation
This form must be accompanied by an affidavit from a physician indicating that the physician agrees the driver
designated below should be re-examined to determine whether or not they could safely operate a motor vehicle.
I believe the following driver should be re-examined:
NAME
ADDRESS
SSN
DOB
DRIVERS LICENSE NUMBER
This driver’s difficulties were brought to my attention because:
The driver was involved in an accident.
The driver committed a traffic violation.
Other (please explain)
Please describe in detail the nature of the disability and how it impairs this person’s ability to drive
safely. Describe the incident and list the names of any witnesses. In addition, please indicate the
date of the occurrence. If additional space is needed, please attach another sheet of paper.
I hereby certify all statements on this affidavit are true and correct to the best of my knowledge. I agree
and understand that if an administrative hearing is held based on my request for re-examination of this
driver, I may be required to appear and testify
.
Name (please print)
Signature
Drivers License Number
Relationship to Driver
Telephone Number
Address
Subscribed and sworn before me this
day of
, 20
Notary Public or
DMV Representative
DLD 23A (Rev. 9-05)
555 Wright Way
Carson City, NV 89711
Reno/Sparks/Carson City (775)
684-4DMV (4368)
Rural Nevada (877) 368-7828
Fax: (775) 684-4829
Website:
www.dmvnv.com
Request for Re-Evaluation
This form must be accompanied by an affidavit from a physician indicating that the physician agrees the driver
designated below should be re-examined to determine whether or not they could safely operate a motor vehicle.
I believe the following driver should be re-examined:
NAME
ADDRESS
SSN
DOB
DRIVERS LICENSE NUMBER
This driver’s difficulties were brought to my attention because:
The driver was involved in an accident.
The driver committed a traffic violation.
Other (please explain)
Please describe in detail the nature of the disability and how it impairs this person’s ability to drive
safely. Describe the incident and list the names of any witnesses. In addition, please indicate the
date of the occurrence. If additional space is needed, please attach another sheet of paper.
I hereby certify all statements on this affidavit are true and correct to the best of my knowledge. I agree
and understand that if an administrative hearing is held based on my request for re-examination of this
driver, I may be required to appear and testify
.
Name (please print)
Signature
Drivers License Number
Relationship to Driver
Telephone Number
Address
Subscribed and sworn before me this
day of
, 20
Notary Public or
DMV Representative
DLD 23A (Rev. 9-05)