OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES APPLICATION FOR IDENTIFICATION CARD FOR HEARING-IMPAIRED DRIVER (Please Type or Print) BMV USE ONLY CARD NO. DATE ISSUED EXP. DATE WHO QUALIFIES: Any person who has a hearing loss of forty decibels or more in one or both ears per Ohio Revised Code (R.C.) 4507.141. INSTRUCTIONS: Application must be completed in the name of the hearing-impaired person. Application must include signature of the hearing-impaired person. Physician's certification must be completed and signed by a licensed physician including his / her physician's license number. WARNING: APPLICANT GIVING FALSE INFORMATION IS SUBJECT TO PROSECUTION (R.C. SECTION 2921.13). NAME OF HEARING-IMPAIRED PERSON ADDRESS (Street) COUNTY SIGNATURE OF HEARING-IMPAIRED PERSON CITY DRIVER LICENSE NUMBER DATE SOCIAL SECURITY NUMBER (Optional) STATE ZIP CODE OHIO X HEARING IMPAIRED I.D. CARD Original Replacement Renewal PREVIOUS CARD WAS Lost Damaged Stolen To be COMPLETED by applicant's personal PHYSICIAN PHYSICIAN'S CERTIFICATION OF APPLICANT'S HEARING IMPAIRMENT NAME OF HEARING-IMPAIRED PERSON ADDRESS (Street) HEARING LOSS IN DECIBELS MUST BE INDICATED ON LINES BELOW CITY STATE ZIP CODE OHIO RIGHT EAR LEFT EAR ) Date Twelve months or more / Permanent BOTH EXPECTED DURATION OF HEARING IMPAIRMENT Less than 12 months (Hearing impairment certified until I, (Signature of PHYSICIAN) X has a hearing impairment as defined below by R.C. Section 4507.141. PHYSICIAN'S NAME (type or print) ADDRESS (Street) CITY certify the above named applicant PHYSICIAN'S LICENSE NUMBER STATE ZIP CODE DATE Send completed application to: OHIO BUREAU OF MOTOR VEHICLES ATTN: SPECIAL CASE UNIT P.O. BOX 16784 COLUMBUS, OH 43216-6784 BMV 6316 9/13 [760-0310] RESTRICTED American LegalNet, Inc. www.FormsWorkFlow.com