PHYSICIAN’S CERTIFICATION OF DISABILITY
This form is to be executed by a physician licensed by the state of New York.
Nature of Disability __________________________________________________________________________
What artificial aid required ___________________________________________________________________
I, ______________________________ Hereby certify that I have examined ____________________________
Name of Applicant
and find Him\Her to have a permanent disability.
DATE: ______________________ _____________________________________________
Signature of Physician
Return this form with application Street Address
Post Office Zip