USVI Public Records

Document text

GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES OFFICE OF THE GOVERNOR BUREAU OF MOTOR VEHICLES PHYSICIAN’S CERTIFICATION BMV FORM NO. (2019-03A) Patient’s Name: Date of Birth: Bellow please indicate the Ty p e of Disability pursuant to Virgin Islands Code Title 3, Chapter 14, Section 233 pertaining to the applicant. Type of Disability: Physical (P) – A physical disability is a physical impairment, disease, or loss, which is of a permanent nature, and which substantially impairs normal physical or motor skills. Developmental (D) - A developmental disability is a disability which originates before the age of 18 years, and results in or has resulted in impairment similar to that caused by a mental disability, and which requires services similar to those required by mentally disabled persons, and which is attributable to mental disability, cerebral palsy, epilepsy, autism, or other conditions or similar disorders. Visual (V) - A visual disability is a disability resulting in complete absence of vision, or vision that with corrective glasses is so defective as to prevent performance of tasks or activities for which eyesight is essential. Hearing (H) - A hearing disability is a disability resulting in complete absence of hearing or hearing that with sound enhancing or magnifying equipment is so impaired as to require the use of sensory input other than hearing as the principal means of receiving spoken language. Mental (M) - A mental disability is an emotional or psychological impairment or disease, which substantially impairs the ability to meet individual or societal needs. I hereby certify under the penalty of perjury, that the conditions of the disabled person named hereon are determined and defined pursuant to Title 3, Chapter 14, Section 233 of the Virgin Islands Code. Physician's Signature: Physician's Name: Date: Tel#: Office Address: Medical License#: SIGN