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