Medical Certification For Disability Exceptions (Page 4 of 4) in pdf

Medical Certification For Disability Exceptions Page 4

4. Did the applicant's disability or impairment result from the illegal use of drugs?

If the applicant is developmentally

disabled, did this condition first manifest itself before age 22? Please explain.

5. What is the duration of the applicant's disability or impairment?

Is it temporary (less than 12 months) or permanent?

Explain.

6. Please provide your medical speciality.

If you are not specialized, provide your medical experience and other

qualifications that permit you to make this assessment.

I certify under penalty of perjury under the laws of the United States of America, that the information on the form and

any evidence submitted with it is all true and correct.

I agree to release this applicant's relevant medical records upon

request from the U.S. Immigration and Naturalization Service.

I am aware that the knowing placement of false

information on the Form N-648 and related documents may also subject me to civil penalties under 8 U.S.C. Section

1324c.

Signature

Date

Please Type or Print

Last Name

First Name

Middle Name

Business Address

City, State, ZIP Code

Telephone

License Number

Licensing State

Form N-648 (06/24/97) Internet Page 4

Medical Certification For Disability Exceptions Page 4