Fillable Physician Certification f or Blind or Disabled Person, (The State of New Jersey)

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Physician Certification f or Blind or Disabled Person, (The State of New Jersey)

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The Physician Certification f or Blind or Disabled Person, (The State of New Jersey) form is 1 page long and contains:

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Country of origin: US
File type: PDF

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Physician Certification f
or Blind or Disabled Person,
Non-Driver ID Application
Visit us at www.NJMVC.gov
New Jersey is an Equal Opportunity Employer
Class K 1/19
A Non-driver ID card is not a license to drive and does
not entitle the holder to park in a
person with a disability parking space. The fee for a Non-driver ID is $6.00; there is no fee for
renewals. This form must be printed, completely filled out, and signed by a physician prior to
applying for an initial Non-driver ID card.
APPLICANT INFORMATION (Please print all information clearly)
Driver License Number (if applicable)
First Name
Middle Name
Last Name
Date of Birth
Address
City State Zip Code
PHYSICIAN’S INFORMATION
Physician’s Name
Medical License Number
State of Issuance
Address
City State Zip Code
I certify that ____________________________________________ has (explain nature of applicant’s condition)
(Please print clearly)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________.
Physician’s Signature: _____________________________________________________________________________________________
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Physician Certification f or Blind or Disabled Person, (The State of New Jersey)

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Completed 26 May 2021

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