Part 85, page 246

Transcript

The scan is the source; the transcript is machine-generated from it.

Examiner will type LAST, FIRST and MIDDLE NAME on line below. CROAK, JAMES ALAN Applicant will print in the following: MAILING ADDRESS: HUTTON HEIGHTS VILLAGE GREEN RIVER (Street or Box No.) (City) (State: WYO.) (Zip) 5'-9 1/2" 150 MALE HAZEL Height (Ft. & In.) (Weight) (Sex) (Eyes)

LICENSE NUMBER Social Security No. 315-28-6472 [redacted] Date of Application 6-24-75 Date of Birth 6-29-32 (Mo Day Year) (Mo Day Year)

TO BE ENTERED BY EXAMINER If a minor (under 18) or if you need a duplicate of a lost license, see entries required on reverse.

CORRECTION DATA FROM PREVIOUS LICENSE OR APPLICATION FOR DUPLICATE NAME CHANGE: If the following data on your present license should be corrected, or if you are surrendering your license for a duplicate name change, copy the information from your present license and enter below: Name was ___ Date of birth was ___ Social security no. was ___

IF YOU ARE APPLYING FOR A NEW LICENSE OR A RENEWAL OF YOUR LICENSE ANSWER THE QUESTIONS BELOW: List your most current license No. L 61 40 23 From what state? WYO. Year issued 1972 Has your license ever been: Revoked NO Suspended NO Denied NO Cancelled NO If so, where ___ When ___ The reason: ___

Have you completed a high school or sponsored driver education course of thirty (30) hours of classroom and six (6) hours of behind the-wheel instruction? NO If so, where ___ When ___ Have you completed a defensive driving course? NO

HAVE YOU EVER BEEN AFFLICTED WITH OR TREATED FOR: Epilepsy NO Blackouts NO Paralysis NO Diabetes NO Heart Condition ___ NO List any other physical disabilities you have that could affect your driving ability: NONE

HOME ADDRESS: If your home address differs from your mailing address listed above, make entry: (Street) (City) (State) (Zip) I hereby certify under penalties provided by law, that the answers to the above questions and any other entries made by me on this application are true and correct. [Signature of applicant: James [guess: A.] Croak]

APPLICATION FOR DRIVERS LICENSE STATE OF WYOMING-DEPARTMENT OF REVENUE & TAXATION D-1 (7-74)

EXAMINER MUST COMPLETE THE FOLLOWING ENTRIES This license will expire on: 6 - 29 - 78 (Mo Day Year) VISION W/Corrective Lens ( ) W/O Corrective Lens (X) Are contacts worn? ___

Vision Right Left Both Screening Eye Eye Eyes 20/20 20/20 20/20 Color blind Yes No No Depth Perception Yes [guess: As] No

RESTRICTIONS - (CODED) May be imposed by examiner ___ L Corrective Lens ___ V Outside Rear View ___ S Power Steering Mirrors ___ T Automatic Trans. ___ H Hand Controls ___ P Gas pedal left foot

RESTRICTION - (CODED) If any of following are believed necessary, forward for departmental approval. ___ D Daylight Driving ___ U City Driving Only ___ X No interstate or primary highway driving ___ Y To submit annual medical/vision certificate ___ Other

TEST RESULTS Written exam 97 Driving ___ Passed [checkmark] Rejected for: Driving ___ Written ___ Vision ___ Physical ___ Physical disability: ___

LICENSE INFORMATION - STATUS - CLASS - TYPE STATUS ___ New X Renewal ___ Duplicate APPLICATION FOR (check one) Cash Other Fees Driver license X $2.50 Duplicate $2.50 Instruction permit $1.00 Duplicate $2.00

CLASS (Circle One or More) A B C M Type (Check one, if applicable) Instruction 1/ Restricted 50 mile radius R/ REMARKS: ___ DATE: 6-24-75 EXAMINER

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