Take application to your physician. A physician must fill out the physician statement and sign. Return the completed application to the Probate Judge or License Commissioner in your county of residence. PRINT OR TYPE ONLY. Full Name: _____________________________
Residence Address: _____________________
Mailing Address (if different): _______________________________________
Date of Birth: ________________________
Age: ________________
Drivers License #: _______________________
Hair Color: __________ Eye Color: __________
Height: __________ Weight: _____________
Signature: _____________________________ Date: ___________ PHYSICIANS ONLY
(Excerpt of SECTION 9-11-54, CODE OF ALABAMA 1975)For the purpose of this license the term “disabled” means inability to engage in any substantial gainful activity by reason of any medically determinable physical impairment which can be expected to result in death or in blindness or to be long continued and indefinite duration. The term “blindness” as used in this section, means central visual acuity of 5/200 or less in the better eye with the use of a corrective lens. An eye in which the visual field is reduced to five degrees or less concentric contraction shall be considered for the purposes of this section as having a central visual acuity or 5/200 or less. Type of Disability: ________________________________________________
If Blindness: Visual Acuity: _________________________________________
Duration of Disability: _____________________________________________
This is to certify that the applicant named above is totally disabled as defined by section 9-11-54 Code of Alabama 1975.
Name of Physician: ________________________________________________
Signature of Physician: __________________________
Date: ______________ |
|
|
