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Request For Medical Exemption To Apply Vehicle Sun-Screening MR-15 - New Jersey

Request For Medical Exemption To Apply Vehicle Sun-Screening Form. This is a New Jersey form and can be used in Motor Vehicle Commission Statewide .
 Fillable pdf Last Modified 3/3/2010
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NEW JERSEY MOTOR VEHICLE COMMISSION West Deptford Regional Service Center 215 C rown Point Road, Suite 100 West D eptford, NJ 08086 REQUEST FOR MEDICAL EXEMPTION TO APPLY VEHICLE SUN-SCREENING The following information is to be completed by the applicant. (Please print or typ e.) Name: Driver License No.: Address: Street City State Zip Code Phone number: ________________________ Vehicle Make Model Year Plate No. Vehicle Identification No. The following information is to be completed by your physician. (Please print or type.) Check the medical condition that may require the application of sun-screening material: poly morphous light eruption persistent light reactivity actinic rectuloid porphyrins solar urticaria lupus erythematosus Description of Patient's condition requiring sun-screening: Recommended treatment: If the condition is dermatological, has photo testing been done to identify the action spectra or wavelength eliciting a photo-sensitive medical condition? Yes No If "Yes," what is the wavelength eliciting photosensitivity:__________ nm or; If "No," what is the action spectra (UVA, UVB, near UV, visible):_________________________________ Physician Information Name: Business Address: Street or P.O Box City State Zip Code Medical License No. : State Date of Licensure I certify, under penalty of law, that the above facts are true and correct to the best of my knowledge. Physician's Signature: MR-15 (R 6/09) Date: (When complete, return to the address above.) American LegalNet, Inc. www.FormsWorkFlow.com
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