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Get Ny Dmv Ds-7 2015

REQUEST FOR DRIVER REVIEW www. dmv.ny. gov INSTRUCTIONS l This form is to be used by concerned citizens to report a driver who appears to be unable to drive safely. Law enforcement personnel must use form DS-5 Police Agency Request for Driver Review physicians must use form DS-6 Physician s Reporting Form. Your Name Print name in full - Required Your Date of Birth Required Client ID No. 9-digit number from your NYS Driver License or Non-Driver ID card Your Home Address Include Street Number - Required Your Daytime Telephone Number Area Code - Required Your relationship to the driver you are reporting o Daughter o Son o Other explain o Sister o Brother o Spouse o Mother o Father o Neighbor PART 3 - Your reasons for reporting this driver Explain why you feel the person you identified in Part 1 should have his/her driving abilities reviewed. Be as specific as possible and include specific incidents observations dates locations etc. DS-7 6/15 Part 3 is continued on Page 2 PAGE 1 OF 2 PART 3 - Continued from Page 1 If you know other people who agree with your assessment of this driver who DMV may contact please identify them below Name Address Daytime Telephone Number PART 4 - CERTIFICATION I certify that the information I provided above is true and accurate. REQUEST FOR DRIVER REVIEW www. dmv*ny. gov INSTRUCTIONS l This form is to be used by concerned citizens to report a driver who appears to be unable to drive safely. Law enforcement personnel must use form DS-5 Police Agency Request for Driver Review physicians must use form DS-6 Physician s Reporting Form. The Department will not act on your request unless you complete all four parts below and on Page 2 and provide all required information* Please provide as much factual detail as possible. Sign the completed original form and mail it to Medical Review Unit New York State Department of Motor Vehicles 6 Empire State Plaza Room 337 Albany NY 12228 Be aware that the review you are requesting may lead to the suspension or revocation of the driver s license of the person you are reporting. PART 1 - Identification of the person whose ability to drive is in question Please print* Last Name Required First Name Required M. I. Date of Birth if not known give approximate age Required Street Address Required City Required State Required Make of Vehicle the Person Normally Drives Color of Vehicle Zip Code License Plate Number PART 2 - Your identification Please print* A representative of the NYS DMV may contact you concerning your request for driver review. I understand that any false statement given by me may be punishable by law. Your Signature - Sign name in full Date - Month/Day/Year reset/clear. Law enforcement personnel must use form DS-5 Police Agency Request for Driver Review physicians must use form DS-6 Physician s Reporting Form. The Department will not act on your request unless you complete all four parts below and on Page 2 and provide all required information* Please provide as much factual detail as possible. .

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