Form PS-15 "Application for Seat Belt Exemption" - Maine

What Is Form PS-15?

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 June 1, 2012;
  • 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 PS-15 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 PS-15 "Application for Seat Belt Exemption" - Maine

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BMV Use Only
MAINE BUREAU OF MOTOR VEHICLES
APPLICATION FOR SEAT BELT EXEMPTION
Placard #: ________________
Issue Date: _______________
 New Application
 Re-Application
 Replacement
Exp Date: ________________
Returned #: _______________
Applicant’s Name:________________________________________
Replaced #: _______________
Issued By: ________________
Address: _______________________________________________
Entered: __________________
_______________________________________________
Daytime Phone #: ______________________________ DOB: _____________
Applicant’s Statement of Understanding:
This removable windshield placard is designed to hang from the rearview mirror when the vehicle is in
motion without obstructing the view of the operator. If the vehicle is not equipped with a rearview mirror,
the placard must be displayed on the dashboard. A placard issued to a person expires when the physician's
certificate expires which may not exceed one year.
Applicant’s Signature:_____________________________________________ Date: _________________
/////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////
Physician’s Statement:
This seatbelt exemption should expire on ___________________ (may not exceed one year).
This patient has a medical condition that warrants an exemption from the requirements of having to wear a
seatbelt while riding in or operating a motor vehicle.
The patient’s specific condition is:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Wearing a seatbelt is a risk for this patient because:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Physician’s Printed Name: ____________________________________________________________________
Signature: ________________________________________________________________Date _____________
Physician’s Address: ________________________________________ License #: ______________________
__________________________________________________________ Phone #:
______________________________
Phone: 207-624-9000 Ext.
52149
Fax: 207-624-9204
TTY Users call Maine Relay 711
PS-15
(06/12)
Mail to: Bureau of Motor Vehicles
Attn: Disability Section
BMV Use Only
MAINE BUREAU OF MOTOR VEHICLES
APPLICATION FOR SEAT BELT EXEMPTION
Placard #: ________________
Issue Date: _______________
 New Application
 Re-Application
 Replacement
Exp Date: ________________
Returned #: _______________
Applicant’s Name:________________________________________
Replaced #: _______________
Issued By: ________________
Address: _______________________________________________
Entered: __________________
_______________________________________________
Daytime Phone #: ______________________________ DOB: _____________
Applicant’s Statement of Understanding:
This removable windshield placard is designed to hang from the rearview mirror when the vehicle is in
motion without obstructing the view of the operator. If the vehicle is not equipped with a rearview mirror,
the placard must be displayed on the dashboard. A placard issued to a person expires when the physician's
certificate expires which may not exceed one year.
Applicant’s Signature:_____________________________________________ Date: _________________
/////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////
Physician’s Statement:
This seatbelt exemption should expire on ___________________ (may not exceed one year).
This patient has a medical condition that warrants an exemption from the requirements of having to wear a
seatbelt while riding in or operating a motor vehicle.
The patient’s specific condition is:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Wearing a seatbelt is a risk for this patient because:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Physician’s Printed Name: ____________________________________________________________________
Signature: ________________________________________________________________Date _____________
Physician’s Address: ________________________________________ License #: ______________________
__________________________________________________________ Phone #:
______________________________
Phone: 207-624-9000 Ext.
52149
Fax: 207-624-9204
TTY Users call Maine Relay 711
PS-15
(06/12)
Mail to: Bureau of Motor Vehicles
Attn: Disability Section