Form 735-24 - Certificate Of Vision
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1
2CERTIFICATE OF VISION
(ORS 807.090)
The medical information in this report is confidential and will be used by the Driver and Motor Vehicle Services (DMV)
only to determine the qualifications of the person to operate motor vehicles.
INSTRUCTIONS TO APPLICANT:
1. Take this certificate to the licensed vision specialist (optometrist or ophthalmologist) of your choice and have a vision
examination.
2. After the vision specialist conducts the examination, dispenses new prescription lenses if necessary, and completes
the certificate:
Return completed form to a local DMV office, or
FAX (503) 945-5329 or mail completed form to DMV Driver Safety Unit, 1905 Lana Ave NE, Salem, OR 97314.
For Valid With Previous Photo License, return completed vision form along with your application in the enclosed
envelope.
Failure to comply with this requirement may result in suspension of your driving privileges.
NOTE
APPLICANT or DMV EXAMINER – COMPLETE THIS SECTION
LAST NAME (PLEASE PRINT)
FIRST NAME
MIDDLE NAME
OFFICE USE ONLY
TSR ID
DATE STAMP
ODL / CUSTOMER NUMBER
DATE OF BIRTH
VISION SPECIALIST – COMPLETE THIS SECTION
Submission of this form may result in an immediate suspension of driving privileges if the applicant does not meet vision standards.
REPORT OF EXAMINATION BY VISION SPECIALIST
(Refer to Vision Standards on Page 2)
Without
With Best Possible
Corrective Lenses
Correction
Right Eye
20 /
20 /
Left Eye
20 /
20 /
Both Eyes
20 /
20 /
Check all that apply:
Applicant's vision meets the eyesight standard stated in OAR 735-062-0050
(Refer to standards on Page 2):
without corrective lenses
with corrective lenses
Driving should be restricted to daylight hours only.
Applicant has a progressive vision impairment and DMV should require the applicant to submit updated
vision information in:
6 months
1 year
Applicant's vision does not meet the eyesight standard stated in OAR 735-062-0050.
Does not meet standards for:
acuity
field of vision
Comments: Please include any vision-related diagnoses that could affect the applicant's ability to drive safely or any other recommendations.
VISION SPECIALIST’S NAME (PLEASE PRINT)
SPECIALTY
LICENSE or CERTIFICATE #
MAILING ADDRESS
TELEPHONE #
FAX #
CITY
STATE
ZIP CODE
COUNTY
SIGNATURE OF VISION SPECIALIST
DATE OF EXAMINATION (MUST be within last 6 months)
DATE SIGNED
X
735-24 (7-17)
STK# 300007
Page 1
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