The document is a certification form for individuals in Maine seeking a credential with a deaf or hard of hearing designation from the Secretary of State's Bureau of Motor Vehicles. The form includes fields for the applicant's name, date of birth, contact information, license number, and address. Applicants must meet one of two qualifications: they must have nonfunctional hearing for communication and primarily rely on visual communication or have a hearing loss resulting in functional loss but not to the extent that they depend primarily upon visual communication. Alternatively, applicants may submit documentation showing enrollment or graduation from a certified school for the deaf. The form includes spaces for a medical care provider's signature and date.
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