Get TX VI-4 2016-2024

Txdps. state. tx. us/rsd/contact/default.aspx Fax to 512 424-2774 Mailing Address Window Tint Medical Exemption P. O. Box 4087 Austin Texas 78773-0543 Please allow up to 15 working days for your application to be processed approved and to receive your exemption certificate. Texas Department of Public Safety Regulatory Services Division www. dps. texas. gov VEHICLE INSPECTION WINDOW TINT MUST USE MOST CURRENT FORM FORM MUST BE TYPED FOR DPS USE ONLY APPLICATION FOR WINDOW TINT MEDICAL EXEMPTION APPLICANT PLEASE USE NAME AS IT APPEARS ON DRIVER LICENSE Name DL Patient Name State Expiration Relationship to Applicant IF DIFFERENT FROM APPLICANT Residence Address City County ZIP Mailing Date of Birth Home Phone Cell Phone Email Business Phone Other Phone VEHICLE INFORMATION Vehicle 1 VIN Year Make Model PHYSICIAN OPTOMETRIST OR OPHTHALMOLOGIST License Phone Zip Fax Vehicle Owner Certification I certify and affirm that all information presented in this form is true and correct that any documents I have presented to DPS are genuine and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation* Applicant / Legal Guardian s Signature Date Completed application must be accompanied by one of the following Letter on physician letterhead signed by the physician indicating the medical reason for the exemption* An original prescription including the applicant s name physician s signature and indicating the medical reason for the exemption* Letters and prescriptions must be dated within one year of exemption request. If the exemption is approved an exemption letter will be sent to the applicant listed above. SUBMIT completed form with required documentation Online Secured Email Contact Us select Vehicle Inspection and complete the online form* http //www. txdps. state. tx. us/rsd/contact/default*aspx Fax to 512 424-2774 Mailing Address Window Tint Medical Exemption P. O. Box 4087 Austin Texas 78773-0543 Please allow up to 15 working days for your application to be processed approved and to receive your exemption certificate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation* Applicant / Legal Guardian s Signature Date Completed application must be accompanied by one of the following Letter on physician letterhead signed by the physician indicating the medical reason for the exemption* An original prescription including the applicant s name physician s signature and indicating the medical reason for the exemption* Letters and prescriptions must be dated within one year of exemption request. If the exemption is approved an exemption letter will be sent to the applicant listed above. SUBMIT completed form with required documentation Online Secured Email Contact Us select Vehicle Inspection and complete the online form* http //www. .