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Get LA DPSMV 2012 2009-2023

____ Birth Date: _____________________ (Address) ____________________________________________________________ Race/Sex: ______________________ _____________________________________________________________________ Driver's License #: ______________ has a physical or mental disability which prevents appropriate restraint in a safety belt and qualifies for a seat belt exemption card. I understand that willful and false certification shall subject me to fines/imprisonment as outlined in R.S. 3.

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