(1) A certificate, signed and dated within six months preceding the date of application, by a licensed physician, a licensed nurse practitioner, a licensed physician associate or a licensed physical therapist to the Department of Transportation that the applicant is a person with a disability or a certificate, signed and dated within six months preceding the date of application, by a licensed optometrist that the applicant is a person with a disability because of loss of vision or substantial loss of visual acuity or visual field beyond correction;
(2) The state-issued licensing number of the licensed physician, certified nurse practitioner, licensed physician associate, licensed physical therapist or licensed optometrist who signed the certificate described in subsection (1) of this section; and
(3) The number of a driver license, driver permit, identification card or parking identification card issued to the applicant by the department.