Form MVL-24 "Certification of Acquired Brain Injury" - Maine

What Is Form MVL-24?

This is a legal form that was released by the Maine Department of the Secretary of State - a government authority operating within Maine. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2021;
  • The latest edition provided by the Maine Department of the Secretary of State;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MVL-24 by clicking the link below or browse more documents and templates provided by the Maine Department of the Secretary of State.

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Download Form MVL-24 "Certification of Acquired Brain Injury" - Maine

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State of Maine
Secretary of State
Bureau of Motor Vehicles
Certification of Acquired Brain Injury
Name: _____________________________________________________________
Date of Birth: _______________________________________________________
Mailing Address:
__________________________________________________________________
__________________________________________________________________
Telephone Number: __________________________________________________
For the purpose of issuing a non-driving card to the person named above, please sign this form
indicating the person named above on this document has an acquired brain injury as defined by
Maine statute, Title 22, Section 3086.
__________________________________________________________________
Licensed Neurologist, Physician, Neuropsychologist Name (printed)
License Number
__________________________________________________________________
Signature
Date
Applicant: Mail this application with a $5.00 check or money order to the address below:
Secretary of State
Bureau of Motor Vehicles
29 State House Station,
Augusta, ME 04333-0029
Attn: Director, Driver License Services
Telephone: (207) 624-9000
TTY Users call Maine relay 711
This card provides no driving privileges and may not be used as a form of
identification.
MVL-24 Rev. 03/2021
State of Maine
Secretary of State
Bureau of Motor Vehicles
Certification of Acquired Brain Injury
Name: _____________________________________________________________
Date of Birth: _______________________________________________________
Mailing Address:
__________________________________________________________________
__________________________________________________________________
Telephone Number: __________________________________________________
For the purpose of issuing a non-driving card to the person named above, please sign this form
indicating the person named above on this document has an acquired brain injury as defined by
Maine statute, Title 22, Section 3086.
__________________________________________________________________
Licensed Neurologist, Physician, Neuropsychologist Name (printed)
License Number
__________________________________________________________________
Signature
Date
Applicant: Mail this application with a $5.00 check or money order to the address below:
Secretary of State
Bureau of Motor Vehicles
29 State House Station,
Augusta, ME 04333-0029
Attn: Director, Driver License Services
Telephone: (207) 624-9000
TTY Users call Maine relay 711
This card provides no driving privileges and may not be used as a form of
identification.
MVL-24 Rev. 03/2021