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DR 2093 042poliza023

The document is an application form for a Colorado Driver License, Instruction Permit, or Identification Card that includes a Disability Identifier Symbol for individuals with disabilities as defined by the Americans with Disabilities Act. It requires personal information from the applicant and a professional statement affirming the applicant's disability and its impact on communication with peace officers. The information will be kept confidential as per relevant laws.

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65 views2 pages

DR 2093 042poliza023

The document is an application form for a Colorado Driver License, Instruction Permit, or Identification Card that includes a Disability Identifier Symbol for individuals with disabilities as defined by the Americans with Disabilities Act. It requires personal information from the applicant and a professional statement affirming the applicant's disability and its impact on communication with peace officers. The information will be kept confidential as per relevant laws.

Uploaded by

arballoruiz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

DR 2093 (11/16/22)

COLORADO DEPARTMENT OF REVENUE


PO Box 173350
Denver CO 80217-3350
DMV.Colorado.gov

Colorado Driver License/Instruction Permit/Identification Card


Application for Disability Identifier Symbol
Full Name

Street Address DL/ID Number (if applicable)

City State ZIP Code

I have a disability as defined in the federal “Americans with Disabilities Act of 1990”, 42 U.S.C.
Sec. 12101 et seq., and the disability interferes with my ability to effectively communicate with a
peace officer. I request that the Department of Revenue issue a driver license, identification card, or
identification document bearing a disability identifier symbol.
I hereby authorize a Professional, as defined in 1 CCR 204-30 Rule 4, to submit information to the
Colorado Department of Revenue - Division of Motor Vehicles (DMV) relating to my disability as
defined in the federal “Americans with Disabilities Act of 1990”, 42 U.S.C. Sec. 12101 et seq. for
the purpose of obtaining a driver license, identification card, or identification document bearing a
Disability Identifier Symbol.
I understand that information received by the DMV will be held in strict confidence per section 42-2-
121, C.R.S., and the federal Driver’s Privacy Protection Act, 18 USC 2721-25.

Signature of Applicant Date (MM/DD/YY)

Professional Statement

Full Name

License or Certificate Number and Issuing US State

Street Address

City State ZIP Code

Page 1 of 2
I affirm, under penalty of perjury:
• The person named above has a disability as defined in the federal “Americans with Disabilities
Act of 1990”, 42 U.S.C. Sec. 12101 et seq., and the disability interferes with the person’s
ability to effectively communicate with a peace officer.
• I am a physician licensed to practice medicine under Section 12-240-107(3)(i), a physician
assistant licensed under Section 12-240-113, a mental health professional licensed or certified
pursuant to Article 245 of Title 12, an advanced practice nurse registered under Section 12-
255-111, a person with a master’s degree in rehabilitation counseling, or a physician, physician
assistant, mental health professional, or advanced practice registered nurse authorized to
practice professionally by another state that shares a common border with Colorado.
Signature of Professional Date (MM/DD/YY)

DR 2093 (11/16/22) Page 2 of 2

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