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APPLICATION FOR SUNSCREENING MEDICAL EXEMPTION ...

STATE OF FLORIDA DIVISION OF MOTORIST SERVICES 2900 Apala chee Parkway, MS# 72 Neil Kirkman Building - Tallahassee, FL 32399-0620 3 APPLICATION FOR SUNSCREENING MEDICAL EXEMPTION SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIO NS, PROVISIONS OF LAW, AND FEES. ** SUBMIT THE COMPLETED APPLICATION TO THE ADDRESS ABOVE ** 1. Original Duplicate Lost-in Transit printed name of the registered owner as it appears on his/her Florida Driver License or Florida ID CardRegistered Owner's First, Middle, and Last Name Registered Owner s Email Address Registered Owner's Address City State Zip Code Mailing Address (if different from above) City State Zip Code Registered Owner's Florida Driver License# or ID Card # Date of Birth Sex 3.

The "Physician's Statement of Certification" section does not have to be completed. The "Lost -in-Transit" block must be checked. No fee is charged for issuing a replacement when the certificate has been lost-in-transit and a completed application is submitted within 180 days of the current issue date.

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