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CTION UNIT 60 STATE STREET, WETHERSFIELD, CT 06161-5056 On the Web at: ct.gov/dmv Telephone: (860)263-5148 Fax: (860)263-5591 INSTRUCTIONS: 1. 2. 3. PART A must be completed by applicant. PART B must be completed by a licensed physician. The applicant must return this form by mail to the address above. This form must be submitted with the Request for a Connecticut Driver's License/Identification Card by Mail (B-350). Physicians (IMPORTANT): If the applicant s medical condition is a chronic h.

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