Form Mvd-10383 - Certificate Of Eligibility For Parking Placard - New Mexico
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2MVD–10383
New Mexico Taxation & Revenue Department - Motor Vehicle Division
REV. 05/11
CERTIFICATE OF ELIGIBILITY FOR
PARKING PLACARD
for Mobility Impaired Individuals
A. Applicant Information
Applicant’s Full Name
Date of Birth
Address
Social Security Number
City, State, Zip Code
Area Code/Telephone Number
(
)
B. Type of Application
ORIGINAL
RENEWAL
REPLACEMENT
Complete items A, C and D in full.
Complete items A and E in full.
Complete items A and E in full.
C: Physician Information
Licensed Physician’s Name
License or Other Identifying Number
Business Address
City, State, Zip Code
Area Code/Telephone Number
(
)
D. Physician Medical Statement & Certification
OFFICIAL USE ONLY
The applicant identified above is eligible for a mobility limitation parking placard because he
or she (check all that apply):
PLACARD
NUMBER(S)
cannot walk 100 feet without stopping to rest;
cannot walk without the use of a brace, cane or crutch or without assistance from
another person, a prosthetic device, a wheelchair or other assistive device;
EXPIRATION
DATE
is restricted by lung disease to such an extent that the person's forced respiratory
month
day
year
volume, when exhaling for one second, when measured by spirometry, is less than one
liter or the arterial oxygen tension is less than sixty millimeters on room air at rest;
DATE POSTED
uses portable oxygen;
TO SYSTEM
month
day
year
has a severe cardiac condition; or
is so severely limited in the ability to walk due to an arthritic, neurologic or orthopedic
condition that the person cannot ascend or descend more than 10 stair steps.
DENIED:
Application
This condition is
Permanent
or
Temporary
inaccurate
A temporary placard should be issued for ______ months (12 months maximum).
incomplete
I certify that the information provided above is true and correct to the best of my
ISSUED
knowledge.
User ID: ______ FO code: ______
_______________________________________________
____________________
Date: ______________
Physician’s Signature
Date
E. Applicant’s Certification for Renewal or Replacement of Parking Placard
I certify that 1) I am the person named as Applicant in Part A of this Certificate of Eligibility; 2) parking placard number
_____________________, expiring on ___________________ was issued to me; and 3) there has been no change in the mobility
limitation condition(s) originally certified by my physician.
If requesting a replacement placard, explain why a replacement is needed: _____________________________________________
_________________________________________________________________________________________________________
_________________________________________________
________________________________
Signature of Applicant
Date
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