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Get TX VI-4 2011

Texas Department of Public Safety Request for Window Tint Medical Exemption Applicant Information Name as it appears on driver license Driver License or State Issued ID State Expiration Date Residence Address City Zip Code Mailing Address Applicant Date of Birth mm/dd/yyyy Residence Telephone Cell Phone Business Telephone Email Address Fax Number if different from residence address Vehicle 1 information Year Make Model VIN Physician Optometrist or Opthalmologist Information Name License Street Address Telephone Applicant Signature Completed application must be accompanied by one of the following Date 1. Letter on physician letterhead and signed by the physician indicating the medical reason for the exemption 2. An original prescription including the applicant s name physician 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 granted an exemption letter will be sent to the applicant listed above Return completed form with attachment to Compliance and Enforcement Service Window Tint Medical Exemption PO BOX 14900 Austin TX 78761-4900 or FAX to 512/424-2774 VI-4 Rev* 3/11. Letter on physician letterhead and signed by the physician indicating the medical reason for the exemption 2. An original prescription including the applicant s name physician 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 granted an exemption letter will be sent to the applicant listed above Return completed form with attachment to Compliance and Enforcement Service Window Tint Medical Exemption PO BOX 14900 Austin TX 78761-4900 or FAX to 512/424-2774 VI-4 Rev* 3/11. .

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Keywords relevant to TX VI-4

  • tint
  • exemption
  • letterhead
  • Applicant
  • Applicants
  • compliance
  • Expiration
  • attachment
  • Mailing
  • prescriptions
  • indicating
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