![]() ![]() episode of marked confusion caused by any condition which may bring about recurring lapses or. ![]() The following conditions that may affect your ability to operate a motor vehicle safely include, but are not limited to: THE FOLLOWING INFORMATION AND CERTIFICATIONS ![]() IT IS IMPORTANT THAT YOU READ AND UNDERSTAND ), Number, Street, Apt/Space No., City, State, Zip CodeĪddress Where You Live ( If different from mailing address ), Number, Street, Apt/Space No., City, State, Zip Code Box, or Private Mail Box ( Include Box Number, St., Ave., Rd., Blvd., etc. READ ALL INFORMATION PROVIDED ON THE FRONT AND BACK OF THIS FORM. PURPOSE FOR YOUR VISIT: 3 the appropriate box(es).
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