The Ps 15 Maine form is an application for a seat belt exemption issued by the Maine Bureau of Motor Vehicles. This form allows individuals with specific medical conditions to obtain a removable windshield placard, permitting them to operate a vehicle without wearing a seatbelt. The exemption is valid for up to one year and requires a physician's certification.
The Ps 15 Maine form serves as an essential tool for individuals seeking an exemption from the seatbelt requirement due to specific medical conditions. This application is divided into two main sections: the applicant's information and the physician's statement. In the first section, applicants provide personal details, including their name, address, and contact information. They must also indicate whether they are submitting a new application, a re-application, or a request for a replacement placard. The form includes a statement of understanding that outlines how to properly display the removable windshield placard, which should hang from the rearview mirror or be placed on the dashboard if no rearview mirror is available. The placard is valid for one year, coinciding with the expiration of the physician's certificate. The physician's section requires a medical professional to confirm the patient's condition and explain why wearing a seatbelt poses a risk. This part of the form must include the physician's printed name, signature, and contact information, ensuring that the exemption is supported by a qualified medical opinion. The completed form must be submitted to the Bureau of Motor Vehicles, specifically to the Disability Section, for processing.
MAINE BUREAU OF MOTOR VEHICLES
APPLICATION FOR SEAT BELT EXEMPTION
___ New Application ___ Re-Application ___ Replacement
Applicant’s Name:________________________________________
Address: _______________________________________________
_______________________________________________
BMV Use Only
Placard #: ________________
Issue Date: _______________
Exp Date: ________________
Returned #: _______________
Replaced #: _______________
Issued By: ________________
Entered: __________________
Daytime Phone #: ______________________________ DOB: _____________
Applicant’s Statement of Understanding:
This removable windshield placard is designed to hang from the rearview mirror when the vehicle is in motion without obstructing the view of the operator. If the vehicle is not equipped with a rearview mirror, the placard must be displayed on the dashboard. A placard issued to a person expires when the physician's certificate expires which may not exceed one year.
Applicant’s Signature:_____________________________________________ Date: _________________
/////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////
Physician’s Statement:
This seatbelt exemption should expire on ___________________ (may not exceed one year).
This patient has a medical condition that warrants an exemption from the requirements of having to wear a seatbelt while riding in or operating a motor vehicle.
The patient’s specific condition is:
__________________________________________________________________________________________
Wearing a seatbelt is a risk for this patient because:
Physician’s Printed Name: ____________________________________________________________________
Signature: ________________________________________________________________Date _____________
Physician’s Address: ________________________________________ License #: ______________________
__________________________________________________________ Phone #: ______________________________
PS-15 (09/09)
Phone: 207-624-9000 ext 52149
Fax: 207-624-9204
Mail to: Bureau of Motor Vehicles
Attn: Disability Section
29 SHS Augusta ME 04333-0029
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