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Get MI OC-88 2011

YOUR SIGNATURE IS REQUIRED TO PROCESS THIS REQUEST. Please print or type other information. Requester s Name and Agency If applicable Telephone Number OC-88 Rev. 09/11 Requester s Signature Authority granted under Act No. 300 of the Public Acts of 1949 as amended. Date SECTION 2 Continued Additional Information Please attach a copy of any related report s. The completed form may be mailed or faxed Michigan Department of State Traffic Safety Division P. O. Please provide a description of an incident or pattern of behavior or other evidence which you believe justifies an evaluation. All sections of this form must be completed. SECTION 1 INFORMATION ABOUT THE DRIVER Please print or type all information. Today s Date Street Address Driver s Full Name As it appears on license Driver License Number City Date of Birth State Zip Code Explain why this driver should be scheduled for an evaluation. Please be specific. Additional space is provided on the back of this form. REQUESTER INFORMATION This section must be completed and signed or the request will not be processed. The Department does not accept anonymous requests. Requests by private citizens to remain confidential will be respected to the extent permitted by Michigan and Federal law. YOUR SIGNATURE IS REQUIRED TO PROCESS THIS REQUEST. Please print or type other information. Requester s Name and Agency If applicable Telephone Number OC-88 Rev. 09/11 Requester s Signature Authority granted under Act No. 300 of the Public Acts of 1949 as amended. Date SECTION 2 Continued Additional Information Please attach a copy of any related report s. REQUEST FOR DRIVER EVALUATION As provided by Section 257. 320 of the Michigan Vehicle Code the Department of State may schedule a driver assessment reexamination on a driver based on evidence of physical infirmities or disabilities vision deficiencies convulsive seizures blackouts episodes or for other reasons that may affect the person s ability to operate a motor vehicle safely. Please provide a description of an incident or pattern of behavior or other evidence which you believe justifies an evaluation. All sections of this form must be completed. SECTION 1 INFORMATION ABOUT THE DRIVER Please print or type all information. Today s Date Street Address Driver s Full Name As it appears on license Driver License Number City Date of Birth State Zip Code Explain why this driver should be scheduled for an evaluation. Please be specific. Additional space is provided on the back of this form. REQUESTER INFORMATION This section must be completed and signed or the request will not be processed. The Department does not accept anonymous requests. REQUEST FOR DRIVER EVALUATION As provided by Section 257. 320 of the Michigan Vehicle Code the Department of State may schedule a driver assessment reexamination on a driver based on evidence of physical infirmities or disabilities vision deficiencies convulsive seizures blackouts episodes or for other reasons that may affect the person s ability to operate a motor vehicle safely. .

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