How Do I Apply?














Certification of Impairment
Part II (to be filled out by a certified professional)

1.I certify that the applicant has the following impairment(s):

Deaf                       Severely Hearing Impaired
Deaf/Blind              Severely Speech Impaired

2. I am a:

Medical Doctor   Audiologist     Speech Pathologist  Qualified State Agent

3. Please provide the following information

NAME
ADDRESS
PHONE

Signature                                                  Date