Application For Disabled Parking Placard/plate - Town Of Hardwick
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2MASSACHUSETTS REGISTRY OF MOTOR VEHICLES
Medical Affairs Branch
P.O. Box 55889
Boston, MA 02205-5889
(617) 351-9222
For Hand Deliveries: 630 Washington St., Boston, MA
APPLICATION FOR DISABLED PARKING PLACARD/PLATE
THIS SIDE OF THE APPLICATION MUST BE COMPLETED IN THE DISABLED PERSON’S NAME
Disabled person must be a Massachusetts resident. Please note the information required in this application may affect your license status.
NOTE: Incomplete applications will not be processed. This application must be submitted to the RMV within thirty (30) days
of the healthcare provider's certification. You should allow at least thirty (30) days for RMV processing. Additional
documentation may be required.
NOTE: REPORT OF CERTAIN MEDICAL CONDITIONS MAY RESULT IN AUTOMATIC LOSS OF LICENSE
Disabled Person's Information (
)
Please Print
________________________________________________________________________________________________
Last Name
First Name
Middle
Gender
________________________________________________________________________________________________
Address
City/Town
Zip Code
____________________________________________________________________________
Date of Birth
Social Security Number (SSN)
Height
Telephone Number
_____________________________________________________________________________________________________________
Driver's License Number or Mass I.D. Number
Is this the first time you have submitted an application for a disabled parking placard/plate?
Yes_______No_________
If applicable, please print your current disabled parking placard or plate number___________________________
I am applying for the Following:
Placard
No fee required for a placard (disabled person's photo must be stored before a placard can be issued).
Plate
Only issued to individuals who have a vehicle registered in his/her name. Registration fees apply.
Motorcycle Only issued to individuals who have a vehicle registered in his/her name. Registration fees apply.
Plate
DV Plate
Only issued to individuals who a) have a vehicle registered in their name; b) meet Medical Affairs
guidelines; c) provide the DV Plate letter from the Veteran's Administration stating that the disability is at
least 80% service connected.
AUTHORIZATION TO RELEASE MEDICAL RECORDS
I hereby authorize the healthcare provider completing this form to discuss and release any or all medical records pertaining to its
content with or to representatives of the Registry of Motor Vehicles.
______________________________________________________
_________________________________
Signature of disabled person
Date
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