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Form Mv-664.1 - Application For License Plates Or Parking Permits For Persons With Severe Disabilities Page 4

MV-664.1 (1/00)

Customers Requesting License Plates, or a Parking Permit, for Persons with a Disability

By signing Part 1 of this application, you are certifying: that the information you provide on this application is true; that

you have read and understand the “Conditions for Using License Plates and Parking Permits” stated on form MV-664.3;

and that you agree to comply with those conditions.

Doctors Providing Medical Information in Support of an Application for License Plates, or a Parking

Permit, for Persons with a Disability

By signing Part 2 of this application, you are certifying: that the medical information you are providing is true and

complete; and that, in your opinion, the person named in Part 1 of the application is medically qualified to receive license

plates, or a parking permit, for persons with a disability, according to the medical criteria specified in Part 2.

Note to Customers and Doctors

It is important for you to know that making a false statement, or providing misinformation, on an application to obtain a

parking permit or license plates for persons with a disability violates Section 1203-a(4) of the NYS Vehicle and Traffic

Law, and Section 210.45 of the NYS Penal Law (violation of this section is a misdemeanor). Such violations are

punishable by fines ranging from $250 to $1,000.

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Form Mv-664.1 - Application For License Plates Or Parking Permits For Persons With Severe Disabilities Page 4