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Get WA DR-500-008 2012

Insufficient information may result in no action. We are unable to divulge the outcome to you however we will provide this form to the driver or their attorney upon written request. Additional witnesses must complete separate forms. Return this form and any additional information or documents to Driver Records Department of Licensing PO Box 9030 Olympia WA 98507-9030 Based on my personal observation and knowledge I request the Department evaluate this driver s qualifications. Name of driver First Middle Last Date of birth Residence address City State ZIP code Driver license number Statement I am concerned that this driver has one or more of the following conditions that may affect their ability to safely drive Medical condition Vision condition Poor driving skills Details Knowledge of this driver is based on observation as a Law enforcement officer Agency Badge number here if there was a collision with a serious injury or fatality and the driver was at fault Check Medical professional Concerned citizen Name of requestor First Middle Last Mailing address Area code Telephone number I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Click here to START or CLEAR then hit the TAB button Driver Evaluation Request You can use this form to request we evaluate an individual s driving ability. You must provide specific information about their medical/visual conditions and/or driving ability. Age is not a consideration* Based on the information provided we will investigate and take action as necessary. Date and place DR-500-008 R/3/12 WA X When you have completed this form please print it out and sign here. You must provide specific information about their medical/visual conditions and/or driving ability. Age is not a consideration* Based on the information provided we will investigate and take action as necessary.

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  • fatality
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