Form 100 - Driver Examination Record
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1
2MISSOURI DEPARTMENT OF REVENUE
DATE
FORM
MISSOURI STATE HIGHWAY PATROL
100
-
-
DRIVER EXAMINATION RECORD
(REV. 11-2010)
IMPORTANT! THIS FORM IS NOT LEGAL FOR DRIVING. YOU MUST APPLY FOR A PERMIT OR LICENSE
AT A MISSOURI DEPARTMENT OF REVENUE CONTRACT OFFICE IN ORDER TO DRIVE LEGALLY. SEE
BACK FOR LICENSE/PERMIT REQUIREMENTS.
DRIVER LICENSE NUMBER/PERMIT NUMBER
STATE
EXPIRATION DATE
-
-
NAME (LAST, FIRST, MIDDLE)
RESIDENCE (STREET OR RFD), CITY, STATE, ZIP
DATE OF BIRTH
SEX
HEIGHT
WEIGHT
EYE COLOR
RESTRICTIONS
TEST RESULTS
VISION
ROAD SIGNS
SKILL
PASS
FAIL
SCORE
ACUITY
LEFT
BOTH
RIGHT
_______
PRE-TRIP
PASSED
_______
BASIC
NO AID
20/
20/
20/
_______
ROAD
_______
CLASS E
FAILED
CORRECTED
20/
20/
20/
_______
CLASS F
_______
SCH BUS (E)
°
°
°
FIELD
_______
MOTORCYCLE
WRITTEN
CLASSIFICATION
CLASS
PERMIT
PASS FAIL SCORE
PASS FAIL SCORE
_______
_______
GEN KNOW
CLASS E
A
E
A
E
_______
_______
COMBINATION
CLASS F
B
F
B
F
_______
_______
AIR BRAKE
MOTORCYCLE
_______
H - HAZ/MAT
C
M
C
M
_______
P - PASSENGER
ENDORSEMENTS
_______
T - DOUBLE
PASSENGER
BP
CP
_______
N - TANK
SCHOOL BUS CDL
BP
CP
X - HAZ/MAT
TANK
SCHOOL BUS (E)
_______
S - SCHOOL
BUS
MOTORCYCLE END
COMMENTS
EXAMINER
BADGE NO.
EXAMINATION SITE
APPLICANT SIGNATURE
X
MO 860-1530 (11-2010)
CONTROL NUMBER
DISTRIBUTION:
WHITE - EXAMINER
CANARY - DEPARTMENT OF REVENUE
PINK - APPLICANT
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