DEPARTMENTOF REVENUE AND TAXATION VEHICLE REGISTRATION BRANCH
Applicants must provide identification
(Guam I.D., Naturalization Certification, Green Card, Firearms
Upon renewal of a temporary placard, applicant must obtain another certification from a physician.
SOCIAL SECURITY NO.
MAILING ADDRESS: __________________________________________
DATE OF BIRTH:
Do you have a current accessible parking placard?
If yes, Placard No(s):
Do you have a current accessible parking license plate?
If yes, License Plate Number:
Please check the appropriate box:
the foregoing is true and correct.
I declare under penalty of perjury that
the release of medical information to process this application.
APPLICANT’ S SIGNATURE:
Section 1. Purpose. The purposes of this act are to establish a uniform system for accessible parking for persons with disabilities to enhance
walk, and to conform to the requirements of
access and the safety of persons who have disabilities, which limit or impair the ability to
Americans with Disabilities Act. Accessibility Guidelines as they apply to accessible parking.
LOSS OF USE OF LOWER LIMBS (5):
Is restricted by lung disease to such an extent that the person’s forced (respiratory) expiatory volume for one second, when
measured by spirometry, is less than one liter, or the arterial oxygen tension is less than sixty (60) mm/hg on room air at rest.
Has a central visual acuity that does not exceed 20/200 in the better eye, with corrective lens, as measured by the Snellen Test, or
visual activity greater than 20/200, but with a limitation in the field of vision such that the widest diameter of the visual field subtends an
angle not greater than 20 degrees.
HEART CONDITION CLASSIFICATION: (By the standards set by the American Heart Association)
OTHER DIAGNOSES DISEASED OR DISORDER, WHICH CREATES A SEVERE WALKING MOBILITY LIMITATION (cannot walk
two hundred feet (200’) without stopping to rest due to):
I, the undersigned, being duly licensed to practice in Guam, certify under the penalties of perjury that I am personally aware of the degree of
impaired mobility of the person identified in this application as indicated above. It is my professional opinion that this applicant should
qualify for the issuance of the special Parking Placard having a condition due to the significant physical mobility limitations and/or for the
safety of the applicant.
NOT TO EXCEED SIX (6) MONTHS
DISAPPROVED (MOBILITY IS NOT AFFECTED BY CONDITIONS(S):
FOR OFFICIAL USE BY DEPARTMENT OF REVENUE AND TAXATION
VEHICLE REGISTRATION BRANCH
PREVIOUS PLACARD NO.