APPLICATION FOR WINDOW TINT EXEMPTION
INDIVIDUAL EXEMPTION FORM
FIRST NAME: Lucien.
ADDRESS (NUMBER & STREET): Tinsel Tower, Boulevard Del Perro.
CITY: Los Santos.
STATE: San Andreas
VEHICLES TO BE REGISTERED FOR EXEMPTION: Maximum of 2
Vehicle: Patriot Mil Spec. Plates: EURO.
Vehicle: Make & Model Plates: XXX###
MEDICAL DIAGNOSIS FOR EXEMPTION: Skip if not applicable | (( Convert cb to cbc for a checkmark ))
Chronic actinic dermatitis/actinic reticuloid
Xeroderma (pigmentosa) pigmentosum
Severe drug photosensitivity provided that the course of treatment causing the photosensitivity is expected to be of prolonged duration
Photophobia associated with an ophthalmic or neurological disorder
If other condition or disorder causing severe photosensitivity in which a person is required to be shielded from sun rays for medical reasons, please fill the field in below: Other: -
EVIDENCE OF MEDICAL DIAGNOSIS: Medical diagnosis must provide the certified medical provider's name, examination date (must be within one month of from the date this form is submitted to the LSPD), and clinic name. Certified medical professional must have a San Andreas certification.
EXEMPTION FOR CREDIBLE THREAT: Credible threat is gauged by submitting a Crime Complaint Report to the Area Detectives Division. Once the Crime Complaint Coordinator has reviewed the presented evidence, they will inform the Traffic Division of approval or dismissal of the application for window tint exemption.
I confirm I have emailed the Crime Complaint Coordinator with a Crime Complaint regarding a credible threat. Date Complaint Filed: DD/MMM/YYYY PART III.
I certify and affirm that all information presented in this form is true and correct, that any documents, including supporting documentation that I have presented to the Los Santos Police Department are true, accurate, and genuine. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal offense.
Signature of Vehicle Registrant: Sign Name in Full