Fillable Application for Sunscreening (The State of New Jersey)

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Application for Sunscreening (The State of New Jersey)

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MVC Sunscreening1 (R3/20)
Form available online at www.NJMVC.gov
Page 1 of 2
Application for Sunscreening
MUST BE INSTALLED BY AN APPROVED INSTALLER
Information - Further instructions on second page
Use this form to apply for a medical exemption for vehicle sunscreening from NJ Motor Vehicle Commission.
Step 1 – What type Sunscreening are you applying for?
Initial application for sunscreening medical exemption
Renewal of sunscreening medical exemp
tion
Step 2 – Enter Vehicle Information
Vehicle Identification Number (VIN)
NJ License Plate Number
Year
Make
Model
Step 3 – Patient/Vehicle Owner Information - Address on application must match the address on the Vehicle Registration
(visit www.njmvc.gov to change your address)
First Name
Driver License Number
Address (Street)
City / Town
State
Zip Code
Phone Number
Co-Owner DL Number (If applicable)
Step 4 – To be completed by physician
Full Name
Medical License No.
State
Date of Licensure
Business Address (Street or P.O. Box)
City / Town
State
Zip Code
Recommended treatment:
I certify, under penalty of law, that the above facts are true and correct to the best of my knowledge.
Physician’s Signature
Date
For medical conditions involving dermatological photosensitivity, signature above certifies that photo testing has
been performed to test skin for radiation wavelengths that elicit a photo reaction.
Motor Vehicle Commission Use Only
Processed by:
Approved/Rejected:
Universal # Issued:
Reason for Rejection (See key on back):
What is the specific wavelength or action spectra of light (UVA, UVB, near UV, visible) to which patient is
photosensitive? __________ nm
1. Polymorphous light eruption
2. Persistent light reactivity
3. Actinic rectuloid
4. Porphyrins
5. Solar urticaria
6. Lupus erythematosus
7. Chronic actinic dermatitis
8. Photosensitive eczema
9. Skin cancers with
Diagnosis of chronic
Actinic dermatitis
Must also submit a valid prescription.
Dup card
MVC Sunscreening1 (R3/20)
Form available online at www.NJMVC.gov
Page 2 of 2
Sunscreening Application Instructions
Instructions:
Step 1 – Type of Transaction
Initial Sunscreening- for first time applicants. If approved, medical exemption will be good for 48 months.
Renewal Sunscreening- previously approved applicants need to reapply for medical exemption every 48 months.
Step 2 – Vehicle Information
Information provided must match your NJ registration information. If approved, your sunscreening exemption will be tied to the
vehicle information provided in step 2.
Step 3 – Patient/Vehicle Owner Information
Information provided on application must match the address on the vehicle registration - visit www.njmvc.gov to change your
address.
Step 4 – Physician information
Your physician must fill out and sign section 4 in in order for your initial or renewal sunscreening application to be reviewed. You
must provide a valid prescription from the same physician to the NJMVC.
Please see N.J.A.C. 13:20-1.5 (a) through (d).
Step 5 – E-mail or Mail-in Application
Once application is completed in its entirety, mail your application along with your valid prescription to:
Customer Advocacy Office Attn:
Sunscreening Exemption
P. O. Box 403
Trenton, NJ 08666-0403
or e-mail to:
SUNSCREENING@mvc.nj.gov
After your application is processed, you will receive a letter correspondence via mail or e-mail from Customer Advocacy.
Submitting your application and prescription does not give you permission to get sunscreening applied to your windows. If
your application is approved, you will receive a letter with a temporary approval, which will allow you to have window
sunscreening installed by an APPROVED INSTALLER ONLY. If you have any questions, the Customer Advocacy Office can be
reached at (609) 984-2973.
Next Steps:
For initial applicants:
1. Receive authorization to install sunscreening (tinting) and Sunscreening Installation Confirmation from NJMVC.
2. Install window sunscreening by an approved installer (list can be found at www.njmvc.gov).
3. E-mail or mail window Sunscreening Installation Confirmation to the address listed in Step 5.
4. Receive permanent window sunscreening authorization document to keep in approved vehicle at all times.
5. Renew every 48 months.
For renewing applicants:
1. Receive permanent window sunscreening authorization document to keep in approved vehicle at all times.
2. Renew every 48 months.
If rejected:
1. You may resubmit your application and valid prescription to the e-mail address or P.O. Box listed in Step 5.
Reasons for Rejection:
A. The medical condition listed does not qualify for vehicle sunscreening per NJ regulation N.J.A.C. 13:20-1.5.
B. Applicant and vehicle information must be completed in its entirety on application.
C. All physician information must be completed in its entirety, signed and legible in Step 4.
D. Dermatological photo testing information must be provided.
E. Missing a valid prescription from your physician requesting sunscreening.
F. Other:_________________________________________________.
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Application for Sunscreening (The State of New Jersey)

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Completed 6 April 2022

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