Form HSMV72120 "Application for Identification Card With Developmental Disability Designation" - Florida

Form HSMV72120 is a Florida Department of Highway Safety and Motor Vehicles - issued form also known as the "Application For Identification Card With Developmental Disability Designation".

A PDF of the latest Form HSMV72120 can be downloaded below or found on the Florida Department of Highway Safety and Motor Vehicles Forms and Publications website.

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Download Form HSMV72120 "Application for Identification Card With Developmental Disability Designation" - Florida

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Division of Motorist Services
Terry L. Rhodes
2900 Apalachee Parkway
Executive Director
Tallahassee, Florida 32399
Robert Kynoch
www.flhsmv.gov
Division Director
Application for Identification Card with Developmental Disability
Designation
Section 322.051, Florida Statute
Applicant Information
Last
First
MI
Date of Birth
Mailing Address:
City
ZIP
Residential Address:
City
ZIP
____________________________________________
_________________
Signature of Applicant or Legal Guardian
Date
Physician's Statement of Certification
Print Name of Certifying Authority
Physician's Certificate/License Number
Business Address
City
State
ZIP
In my professional opinion, ____________________________________________(Print Applicant's Name)
has been diagnosed as having a developmental disability as defined in §393.063 of the Florida Statute.
______________________________________
____________________
_________________
Signature of Certifying Authority
Contact Number
Date
HSMV 72120
Division of Motorist Services
Terry L. Rhodes
2900 Apalachee Parkway
Executive Director
Tallahassee, Florida 32399
Robert Kynoch
www.flhsmv.gov
Division Director
Application for Identification Card with Developmental Disability
Designation
Section 322.051, Florida Statute
Applicant Information
Last
First
MI
Date of Birth
Mailing Address:
City
ZIP
Residential Address:
City
ZIP
____________________________________________
_________________
Signature of Applicant or Legal Guardian
Date
Physician's Statement of Certification
Print Name of Certifying Authority
Physician's Certificate/License Number
Business Address
City
State
ZIP
In my professional opinion, ____________________________________________(Print Applicant's Name)
has been diagnosed as having a developmental disability as defined in §393.063 of the Florida Statute.
______________________________________
____________________
_________________
Signature of Certifying Authority
Contact Number
Date
HSMV 72120
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