New Jersey Form Mr 15 – Fill Out and Use This PDF

New Jersey

Motor Vehicle Commission

Information enclosed references legislation that allows sun-screening material for explicit medical reasons such as poly morphous eruption, persistent light reactivity, actinic reticuloid, porphyrins, solar urticaria, and lupus erythematosus.

To apply for sun-screening material, please complete the enclosed application and return to the Motor Vehicle Commission (MVC). The application is to be fully completed by you and your physician. Incomplete or missing information will be cause for rejection. This application does not grant you permission to have sun- screening material applied to your vehicle. All unauthorized sun-screening materials installed are subject to removal, fines and failure to pass New Jersey inspection. Upon sale of vehicle or transfer of license plates, you must return your Medical Exemption for Sun-Screening Certificate to the MVC.

Upon review and approval by MVC you will be issued a “Medical Exemption for Vehicle Sun-Screening Certificate”. This certificate will reflect the type of sun- screening material to be applied to a specific vehicle and windows. Applicants approved for sun-screening materials are responsible for removal of this material prior to the sale or transfer of the exempted vehicle.

You must adhere to the New Jersey tint regulation (N.J.A.C. 13:20-1.1-1.8) requirements listed below:

•All medical sun-screening materials must be applied to the portion of the windshield above the AS-1 line. To reduce the transmittance of normally incident light reflection below 70%.

•The sun-screening materials could be applied to the upper most portion of the front side window. To reduce visible light below 35%.

•The sun-screening materials applied to the windshield or front side windows shall not exceed 8%.

•All sun-screening materials applied must be of clear film.

Please visit the MVC Website www.state.nj.us/mvc/Licenses/sunscreening.htm for a list of licensed tinting facilities.

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New Jersey is an Equal Opportunity Employer

REQUEST FOR MEDICAL EXEMPTION TO APPLY VEHICLE SUN-SCREENING

The following information is to be completed by the applicant. (Please print or type.)

Name:							Phone number: ________________________
Driver License No.:
Address:
				Street	City			State	Zip Code
Vehicle
		Make		Model	Year	Plate No.		Vehicle Identification No.

The following information is to be completed by your physician. (Please print or type.)

Check the medical condition that may require the application of sun-screening material:

poly morphous light eruption

persistent light reactivity

actinic rectuloid

porphyrins

solar urticaria

lupus erythematosus

Description of Patient's condition requiring sun-screening:

Recommended treatment:

If the condition is dermatological, has photo testing been done to identify the action spectra or wavelength eliciting a

photo-sensitive medical condition?

Yes

No

If "Yes," what is the wavelength eliciting photosensitivity:__________ nm or;

If "No," what is the action spectra (UVA, UVB, near UV, visible):_________________________________

Physician Information

Name:

Business Address:

	Street or P.O Box		City	State	Zip Code
Medical License No.:		State		Date of Licensure

I certify, under penalty of law, that the above facts are true and correct to the best of my knowledge.

Physician's Signature:		Date:

(When complete, return to the address above.)

MR-15 (R 6/09)