Form N-648 - Medical Certification For Disability Exceptions - U.s. Department And Immigration Services Page 3

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Applicant's Name
USCIS A-Number
A-
Name of Regularly Treating Medical Professional and Address
Last Name
First Name
Middle Name
Business Address (Street Number and Name)
City
State or Province
Zip Code or Postal Code
Telephone Number
Explanation
6. Has the applicant's disability and/or impairments lasted, or do you expect it to last, 12 months or more?
Yes (If "Yes,"continue to complete this form.)
No (If "No," the applicant is not eligible for this exception and you need not complete the remainder of the questions. Please go directly to
the "Medical Professional's Certification.")
7. Is the applicant's disability and/or impairments the result of the applicant's illegal use of drugs?
Yes (If "Yes," the applicant is not eligible for this exception and you need not complete the remainder of the questions. Please go directly to
the "Medical Professional's Certification.")
No (If "No," continue to complete this form.)
8. What caused this applicant's medical disability and/or impairments listed in number 1, if known?
Form N-648 03/21/17 Y Page 3

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