B Medical Certification

Section 100 Section 100.APPENDIX B   Medical Certification Please fill out this statement and return to the following address: I certify that suffers from a serious health condition which can be ameliorated by cooling facilities. Illness or medical condition: Asthma Respiratory Allergies (requiring filtered air) Severe obstructive lung disease Severely debilitating stroke Any medical condition of a non-ambulatory patient Other – please specify: Signature: Name and Title/Degree: Practice or Organization Name: Registration No. I hereby authorize this agency to verify that information provided by me and to contact my physician or other public health official for the purpose of securing medical certification as described above. Name of Applicant Signature of Applicant Date Social Security Number of Applicant