2) 673-9908. This form is only valid within 60 days of the date of Medical Practitioner/Ophthalmologist/Optometrist signature. Visit our website: www.dmv.dc.gov or call 311 or 202-737-4404 for additional information. This section must be completed by the customer. LAST NAME FIRST NAME ADDRESS APT/UNIT # DATE OF BIRTH (MM/DD/YYYY) Alzheimer Yes No CITY STATE WASHINGTON TELEPHONE NUMBER DLN/IDN/SSN MEDICAL REPORT: MIDDLE NAME ZIP CODE DC E-MAIL ADDRESS This section must be c.
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