Fillable Printable Nc Dmv Bioptic Driving Form
Fillable Printable Nc Dmv Bioptic Driving Form
Nc Dmv Bioptic Driving Form
ver 02/17
NORTH CAROLINA DIVISION OF MOTOR VEHICLES
CERTIFICATE OF BEHIND-THE-WHEEL BIOPTIC DRIVER TRAINING
FORM DL77-BT
Applicant Name License/Customer Number
Date of Birth Age
Parent/Guardian if Minor Telephone Number
Signature of Applicant Date
INFORMATION:
Visually impaired individuals may be eligible to receive a restricted driver license with the use of a bioptic telescope if they
can achieve at least 20/200 visual acuity in one or both eyes through conventional eyeglass lenses (if needed) and at least
20/70 visual acuity in one or both eyes through a bioptic telescope. Individuals must also have a minimum visual field radius
of at least 30 degrees nasally and 40 degrees temporally without the use of field expanders and demonstrate satisfactory
driving skills with the use of the bioptic telescope. A current DMV Vision Form (DL77), which is not more than 6 months old,
must accompany this certificate.
1. If the applicant is younger than 18 years of age, has the applicant completed:
a. 30 hours of classroom Driver Education instruction
b. pre-driver readiness
c. minimum of 10 hours of BTW training with the use of a bioptic telescope by
a certified driving instructor (CDI) bioptic trainer
Yes No
Yes No
Yes No
2. The applicant has driven safely on local roads.
3. The applicant can locate, identify, and respond to signs and signals at appropriate distances.
4. The applicant recognizes and responds appropriately to road hazards, traffic, and pedestrians.
5. Is the applicant’s vision with conventional lenses (if needed) at least 20/200 in one or both eyes
and at least 20/70 through the telescope?
5a. If yes, has the applicant successfully driven on highways and interstates
at appropriate posted speeds?
5b. If yes, can the applicant safely enter and exit highways and interstates?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
6. Does the applicant have 20/40 or better visual acuity through the bioptic in one or both eyes?
6a. If yes, has the eyecare provider approved the applicant for night time driving?
6b. If yes, has the applicant driven successfully at night-time with their bioptic telescope?
Yes No
Yes No
Yes No
7. Do you have any additional concerns regarding this individual’s fitness to operate a motor vehicle? Yes No
If yes, please explain:
This is to confirm that the applicant has completed supervised behind-the-wheel driver training and assessment while using a
bioptic telescope and shows competence operating a motor vehicle in a safe and responsible manner while using a bioptic
telescope.
I hereby certify that the applicant is competent to drive with a bioptic telescope as noted above.
Signature Date
Name Degree License #
Company/Agency/Program
Address
Phone Fax
Instructions: Fax this completed and signed form to the NC DMV Medical Review Section at (919) 733-9569.
Division of Motor Vehicles, Medical Review Unit, 3112 Mail Service Center, Raleigh, NC 27697-3112
Phone: (919) 861-3809
