ELIGIBILITY REQUIREMENT -- Check only one box
Certification signature required. Certifier cannot be a relative or the applicant.
In cases of blindness, visual and/or physical disabilities, the following persons may certify:
M.D., D.O., R.N., Ophthalmologist, Optometrist, therapist, and professional staff of hospitals, institutions, libraries, schools and public or private welfare agencies.
In the case of a Reading Disability, a M.D. or D.O. must certify this application.
I certify the applicant is unable to read or use standard printed material for the reason indicated above.
(MUST INCLUDE SIGNATURE OR STAMP OF CERTIFYING AUTHORITY TO BE PROCESSED.)