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Ohio Application Identification Impaired  Form

Ohio Application Identification Impaired Form

Use a Ohio Application Identification Impaired template to make your document workflow more streamlined.

Certification must be completed and signed by a licensed physician including his / her physician’s license number. WARNING: APPLICANT GIVING FALSE INFORMATION IS SUBJECT TO PROSECUTION (R.C. SECTION 2921.13). NAME OF HEARING-IMPAIRED PERSON SOCIAL SECURITY NUMBER (Optional) ADDRESS (Street) CITY STATE ZIP CODE OHIO COUNTY DRIVER LICENSE NUMBER SIGNATURE OF HEARING-IMPAIRED PERSON DATE X HEARING IMPAIRED I.D. CARD Original Replacement Renewal PREVIOUS CARD WAS Lost Damaged Stolen To...
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