Form DSMV 643 template
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Medically Recognized Disorder Indication application
This document is a form used by the New Hampshire Department of Safety, Division of Motor Vehicles, to add a medically recognized indication of Autism Spectrum Disorder to an individual's driver license or identification card. The applicant must provide their current driver license or non-driver ID information, date of birth, address, and signature. A licensed physician must complete a certification section, attesting to the diagnosis of Autism Spectrum Disorder. The form includes a disclaimer, warning against false completion under penalty of law.
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