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New York State Department of Motor Vehicles

MV-664.1 (1/00)

APPLICATION FOR LICENSE PLATES OR PARKING PERMITS

FOR PERSONS WITH SEVERE DISABILITIES

Part 1 INFORMATION ABOUT PERSON WITH DISABILITY

—(Please print, and sign by the arrow.)

Last Name

First

M.I.

Telephone No.

(

)

Address: No. and Street

Apt. No.

City

State

Zip Code

Date of Birth

I am applying for:

License Plates

Parking Permit

Male

Female

have

do not have license plates for persons with disabilities. If “Yes”, my license plate number is:__________________

(Signature of Person with Disability or Signature of Parent or Guardian) —

If signed by parent or guardian,

(Date)

please state your relationship to the person with the disability after your signature.

Part 2 MEDICAL CERTIFICATION—

This section must be completed only by a Medical Doctor (MD), Doctor of Osteopathy

(DO) or Doctor of Podiatric Medicine (DPM) . Please certify whether the patient’s disability is permanent or temporary.

Check the box(es) that describe the disability, and fill in the diagnosis:

TEMPORARY DISABILITY: A person with a temporary disability is any person who is temporarily unable to ambulate without

the aid of an assisting device, such as a brace, cane, crutch, prosthetic device, another person, wheelchair, walker or other assistive

device. (Temporary permits are issued for periods of six months or less.)

_______________________

Expected Recovery Date

Diagnosis:_____________________________________________________________________________________________

What assistive device is needed? __________________________________________________________________________

PERMANENT DISABILITY: A “severely disabled” person is any person with one or more of the PERMANENT impairments,

disabilities or conditions listed below, which limit mobility.

Diagnosis:____________________________________________________ Please check the conditions that apply:

Uses portable oxygen

Legally blind

Limited or no use of one or both legs

Unable to walk 200 ft. without stopping

Neuromuscular dysfunction that severely limits mobility

Class III or IV cardiac condition. (American Heart Assoc. standards)

Severely limited in ability to walk due to an arthritic, neurological or orthopedic condition

Restricted by lung disease to such an extent that forced (respiratory) expiratory volume for one second, when measured by

spirometry, is less than one liter, or the arterial oxygen tension is less than sixty mm/hg of room air at rest

Has a physical or mental impairment or condition not listed above which constitutes an equal degree of disability, and which

imposes unusual hardship in the use of public transportation and prevents the person from getting around without great

difficulty. Explain how this disability limits functional mobility.

______________________________________________________________________________________________________

MD/DO/DPM Name

Professional License No.

Telephone No.

MD/DO/DPM Address

(

)

(MD/DO/DPM Signature)

(Date)

Part 3 FILE INFORMATION

(For Issuing Agent Use Only):

Parking Permit No. _______________

PERMIT:

Permanent

Temporary

Issuance Date: ________________

First

Second

Expiration Date: ________________

Denied

Revoked Reason:_____________________________________________________

______________________

(Date)

___________________________________________________________________________________

____________________________________________

(Issuing Agent)

(Locality)

_____________________________________________

PAGE 3 OF 4

Form Mv-664.1 - Application For License Plates Or Parking Permits For Persons With Severe Disabilities Page 3

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