MAINE BUREAU OF MOTOR VEHICLES
APPLICATION FOR SEAT BELT EXEMPTION
___ New Application ___ Re-Application ___ Replacement
Applicant’s Name:________________________________________
Address: _______________________________________________
_______________________________________________
BMV Use Only
Placard #: ________________
Issue Date: _______________
Exp Date: ________________
Returned #: _______________
Replaced #: _______________
Issued By: ________________
Entered: __________________
Daytime Phone #: ______________________________ DOB: _____________
Applicant’s Statement of Understanding:
This removable windshield placard is designed to hang from the rearview mirror when the vehicle is in motion without obstructing the view of the operator. If the vehicle is not equipped with a rearview mirror, the placard must be displayed on the dashboard. A placard issued to a person expires when the physician's certificate expires which may not exceed one year.
Applicant’s Signature:_____________________________________________ Date: _________________
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Physician’s Statement:
This seatbelt exemption should expire on ___________________ (may not exceed one year).
This patient has a medical condition that warrants an exemption from the requirements of having to wear a seatbelt while riding in or operating a motor vehicle.
The patient’s specific condition is:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Wearing a seatbelt is a risk for this patient because:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Physician’s Printed Name: ____________________________________________________________________
Signature: ________________________________________________________________Date _____________
Physician’s Address: ________________________________________ License #: ______________________
__________________________________________________________ Phone #: ______________________________