Request For Medical Exemption To Apply Vehicle Sun-Screening
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Request For Medical Exemption To Apply Vehicle Sun-Screening Form. This is a New Jersey form and can be use in Motor Vehicle Commission Statewide.
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Tags: Request For Medical Exemption To Apply Vehicle Sun-Screening, MR-15, New Jersey Statewide, Motor Vehicle Commission
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:
Phone number: ________________________
Driver License No.:
Address:
Street
City
State
Zip Code
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
Medical License No. :
City
State
State
Zip Code
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:
Date:
(When complete, return to the address above.)
MR-15 (R 6/09)
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