Transcription of Physician's Statement of Certification
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Example: dental hygienist
Physician's Statement of Certification
flhsmv FLORIDA HIGHWAY SAFETY ANO MOTOR VEHICLES Division of Motorist Services Terry L. Rhodes 2900 Apalachee Parkway Executive Director Tallahassee, Florida 32399 Robert Kynoch Division Director Application for Developmental Disability Designation Applicant Information Last First MI Date of Birth Mailing Address: City ZIP Residential Address: City ZIP _____ _____ _____ Signature of Applicant, Parent, or Legal Guardian Applicant s ID/DL Number, if Date applicable Physician's Statement of Certification Print Name of Physician Physician's Certificate/License Number Business Address City State ZIP _____ (Print Applicant s Name) is applying for a disability designation on their DL ID (Indicate whether this is for a driver license or identification card) In my professional opinion, this individual has been diagnosed as havi
HSMV 72120 Division of Motorist Services 2900 Apalachee Parkway Tallahassee, Florida 32399 www.flhsmv.gov Terry L. Rhodes Executive Director Robert Kynoch
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