New Applicant:
	I have enclosed a recent color photo of my face (top of head and bottom of chin must be showing) for use in the preparation of my I.D. card. I have printed my name on the back of the photo. I have enclosed a $5.00 check/money order for a new card.
Replacement Card Requested (lost, stolen or damaged cards):
	I have enclosed a recent color photo of my face (top of head and bottom of chin must be showing) for use in preparation of my ID card. I have printed my name on the back of the photo. I have enclosed a $10.00 check/money order for a replacement card.

Mr.            Mrs.            Miss            Ms. 

Last Name:  

First Name:  

MI:  

Permanent Street Address:  

Apt.#:  

City or Town/State/Zip Code:  

Date of Birth:  

Phone:  

e-mail:  

Written Signature of Applicant or Guardian:

Please fill out Either Section A--OR--Section B but not both.

SECTION A: Disabled Certification
I am a "person with a disability" as described in the definition in the instructions.

Physician's Statement:I have examined the applicant identified above, and it is my opinion that (s)he is a person with a disability as described in the definition in the instructions

I estimate that the duration of the impairment will be:

	Temporary (over 3 months but under 12 months) - A one-year card will be issued. (see "new applicant" information above).
	Permanent - A permanent card will be issued.

Physician's signature date



Physician's printed name                               phone number



Physician's license number

SECTION B: Senior Citizen Certification
I am 65 years of age or older as of the date of this application.

Notary's Statement: I have seen the applicant identified above and the applicant has shown me:

Form of ID (Birth certificate/alien registration card, etc.)

I am attesting to the fact that the applicant is 65 years of age or older.

Notary/Town Clerk/Registrar of Voters                     Date

Seal/Stamp Required