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HEARNAP — Part 13
Page 487
487 / 693
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APPLICATION NO, 2 / YEO
ep PRA O48 att) C00 08400 Beet OF wEevERNE EO TEO BEE, wv.
| Ly DECLARATION SHEET
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1 FULL NAME
3 RESIDENCE o Ew seh
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Bee DOU waar LE CFELC Conse Cag
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gory! f COLOR COLOR
oe Tic DLO mom ed DE eyes LF2E2.
- an DATE OF —
i oh wonta JAVUAR ay 22. year !WSise 27
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PRESENT DRIVERS ©, YEAR
cee y LICENSE NUMBER diy PL STATE Cali e ssueo 7
.
p++ ANSWER THE FOLLOWING QUESTIONS BY “CHECKING YES OR NO . bw?
1 1. t$ YOUR DRIVING PRIVILEGE UNDER SUSPENSION,
" REVOCATION OR DENIAL AT THIS TIME?
4 2. WERE YOU CONVICTED OF ANY TRAFFIC La¥
| VIOLATION DURING THE LAST THREE YEARS? YES NO
a w WERE YOU INVOLVED 1X AN ACCIDENT DURING THE 7 7
SS LAST THREE YEARS? . ae ves NOE
g i WERE YOU EVER TREATED FOR OR COMMITTED 3 1 A: ' a
; HOSPITAL FOR aN EMOTIONAL OR MENTAL CONDITION? Yes) NO
- DO YOU HAVE HEART TROUBLE, EPILEPSY, DIABETES,”
' | PARALYSIS, SEIZURES, CONVULEIONS, LAPSES CF
" COHSCIOUSNESS OR ANY OTHER PHYSICAL HANDICAR~ oT te
OR DISABILITY? _ ves ee
tHEREBY CERTIFY THAT JHE ABGVE INFORMATION GIVEN IS TRUE
AND CORRECT AND J UNDERSTAND THAT ANY FF ALSE (NFGRMATION
GIVEN WILL BE CAUSE FOR canctan N OF BY. YORIVE! 3 LICENSE.
SIGNATURE OF avoricanr BLLM é 1 eI
7 OO NGT WRITE IM THIS SPACE
| WRITTEN: series__/¥ E10 crave J 2 Ep— RonD sIGNs passeor] & Us.
eZ vision: withouTcoRRECTION R.20/ 28 %..3 L.20/ 2° pers 207 B0" 3S
~ CORRECTIVE GLasses: R.70/3% 1.20/_ 30 tom w/ AL "AQ
sepee, 1. . CONTACT LENS: R.20/___.20/____ Beth 04__
“2 [EOLOR BLIND: YEST) NO SR HEARING GUOD RS HOF MI Dear Cy,
LT 2 RESTRICTIONS AND REMARKS:
ere
GUSMEONTIVE LER
. NO DRIVE Bf] orive (Af A.C. END. =)
“ SUBSCRIBED AND SWORN TO SEFORE ME THIS OTE: MAR 15 ja
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