Fillable STATE OF NEVADA Highway Patrol Division (Department of Motor Vehicles )

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STATE OF NEVADA Highway Patrol Division (Department of Motor Vehicles )

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DEPARTMENT OF PUBLIC SAFETY
Highway Patrol Division
The following is an application for exemption from the Nevada Window Tint guidelines as set forth in NRS 484D.440;
NAC 484D.280 thru .290.
Street/Road
Street/Road
City
State
City
State
Please list the vehicle's for which this permit has been requested:
Form DO - 200, Window Tint Exemption Application (-)
Application for Window Tint Exemption
Name:
First
STATE OF NEVADA
MI
Mailing Address:
Legal Address:
(if different)
Phone No:
Drivers License No:
Date of birth:
Registered
Owner:
Make: Model:
PRIMARY VEHICLE
Year:
VIN:
Plate Number:
Registered
Owner:
Make: Model:
SECONDARY VEHICLE
VIN:
Plate Number:
Year:
A completed application must be submitted to:
Nevada Highway Patrol, Department of Public Safety
555 Wright Way, Carson City 89711
If approved, the original will be forwarded back to the applicant and serve as authorization for exemption to the
window tint law based on identified and approved criteria set forth in this document. The approved document, or
copy of, must be carried in the vehicle at all times.
Last
SECTION 1 - Application
Zip Code
Zip Code
* No window tint exemption less than 20% VLT will be approved by the Department of Public Safety.
Print Form
Recommended Percentage of Visible Light Transmittance (VLT) for Applicant:
Declaration: I hereby certify it is a medical necessity that the windows of the aforementioned motor vehicle (s) be tinted
for the purpose stated above for said Applicant's medical condition.
DEPARTMENT OF PUBLIC SAFETY
Highway Patrol Division
STATE OF NEVADA
SECTION 2 - MUST BE completed by a currently licensed State of Nevada Physician
Clinical Diagnosis (explanation of exact nature of the impairment)
VLT Percentage
Recommended duration of permit for Applicant (check one):
4 - year permit (temporary condition)
Indefinite (permanent-stable condition)
Physician's Signature DatePhysician's Name (please print)
Street/Road
City
State
Mailing Address:
Zip Code
Phone No:
License No:
Please check the rationale for the application of this exemption:
Declaration: I hereby certify that the above information is true and correct and I am the Primary Driver of all
vehicles listed on this application. I further attest that I have read and understand the law surrounding my
application for exemption and agree to abide by the conditions outlined. (It is a felony to knowingly make any false or
fictitious statement or entry on this form. If any such statement or entry is made, the signatory will be subject to criminal prosecution.)
MEDICAL (SECTION 2 MUST also be completed and submitted).
OTHER (SECTION 3 MUST also be completed and submitted).
Applicant Signature
Date signed
Sheet 2 of 3
Form DO - 200, Window Tint Exemption Application (-)
20%
DEPARTMENT OF PUBLIC SAFETY
Highway Patrol Division
STATE OF NEVADA
SECTION 3 - MUST BE completed by Applicant for NAC 484D.285 exemptions.
Please check the rationale for the application of this exemption:
The motor vehicle(s) referenced in this application are operated
Declaration: I hereby certify that the above information is true and correct. (It is a felony to knowingly make any false or
fictitious statement or entry on this form. If any such statement or entry is made, the signatory will be subject to criminal prosecution.)
Exclusively as an Ambulance or Hearse (Copy of the permit issued must be submitted).
by Fed, State or Local Law Enforcement for canine transportation ,surveillance, undercover or forensic purposes .
Page 3 of 3
Applicant Signature
Date signed
Business/Agency Name:
Mailing Address:
Phone No:
Drivers License No:
Zip Code
State
City Street/Road
This letter of exemption is valid for the period indicated and must be carried, at all times, in the vehicle(s) described
above. If the vehicle is sold, this waiver is not transferable, and this letter must be returned to the Department of
Public Safety at the above-referenced address.
Exemption approved for 4 years.
Exemption approved indefinitely.
Signature DPS Director
Name DPS Director
Date
Signature NHP Chief
Name NHP Chief
Date
VLT Percentage
Visible Light Transmittance (VLT) for Application approved at:
* No window tint exemption less than 20% VLT will be approved by the Department of Public Safety.
Form DO - 200, Window Tint Exemption Application (-)
DEPARTMENT USE ONLY SECTION - DO NOT WRITE BEYOND THIS POINT
20%
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STATE OF NEVADA Highway Patrol Division (Department of Motor Vehicles )

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Completed 24 December 2020

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