DS 699 A (REV. /201) WWW SELF REFERRAL FOR REEVALUATION OF DRIVING SKILLINSTRUCTIONS:1.Please complete this form if you wish the Department of Motor Vehicles (DMV) to reevaluate yourability to drive safely.PLEASE NOTE: Submission of this form to DMV initiates a reexamination of your licensinghistory information from you and your physician.YOUR NAMEYOUR DRIVER LICENSE NUMBERYOUR BIRTH DATETELEPHONE NUMBER( )YOUR ADDRESSCITYSTATEZIP CODE(OPTIONAL) I AM REQUESTING THIS REEVALUATION BECAUSE:YOUR SIGNATUREXTODAY222S DATE STATE OF CALIFORNIADEPARTMENT OF MOTOR VEHICLES256A Public Service Agency*DS699A* American LegalNet, Inc. www.FormsWorkFlow.com DS 699 A (REV. /201) WWW DEPARTMENT OF MOTOR VEHICLESDRIVER SAFETY OFFICESBAKERSFIELDREDDING CITY OF COMMERCESACRAMENTOCITY OF ORANGESAN BERNARDINOCOVINASAN DIEGOEL SEGUNDOSAN FRANCISCOFRESNOSAN JOSEOAKLANDSTOCKTONOXNARD VAN NUYS American LegalNet, Inc. www.FormsWorkFlow.com