Form Mv-145a - 2013 Person With Disability Parking Placard Application

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MV-145A (3-13)

www dot state pa us

FOR DEPARTMENT USE ONLY

Bureau of Motor Vehicles • P.O. Box 68268 • Harrisburg, PA

17106-8268

CHECK ( 4 ) APPROPRIATE BLOCKS BELOW

ORIGINAL REQUEST -

Permanent Placard

Severely Disabled Veteran

Temporary Placard

RENEWAL REQUEST - (For Permanent Placards Only)

REPLACEMENT REQUEST -

PLACARD

ID CARD

Defaced

Lost

Stolen

Never Received

PREVIOUS PLACARD # _______________

CHANGE OF ADDRESS/NAME

APPLICANT INFORMATION - LIST NAME AND ADDRESS OF PERSON WITH DISABILITY

Last Name (or Full Business Name)

First Name

Middle Name

PA DL/Photo ID# or

Date of Birth

Bus. ID#

Street Address

City

State

Zip Code

NOTE: If you are the parent or adult charged by law with the natural parent’s rights, duties and responsibilities acting on behalf of a minor child

(under 18) in place of the child’s natural parents (person in loco-parentis), you must complete the information below.

Name of Parent or Person in Loco Parentis

Relationship to Applicant

Age of Applicant Listed

in Section A

Street Address

City

State

Zip Code

CERTIFICATION FROM A HEALTH CARE PROVIDER LICENSED OR CERTIFIED IN PA OR A CONTIGUOUS STATE (NEW YORK, NEW JERSEY,

DELAWARE, MARYLAND, WEST VIRGINIA OR OHIO). THIS SECTION MUST BE COMPLETED IN FULL. HEALTH CARE PROVIDERS MAY ONLY

CERTIFY DISABILITIES WITHIN THEIR SCOPE OF PRACTICE. WARNING: Altering or forging a document issued by the Department, such as a

disabled person parking placard, or possessing, using or displaying, such a document knowing it to have been altered, forged or counterfeited,

is a misdemeanor of the first degree pursuant to the Vehicle Code, 75 Pa.C.S. Section 7122, punishable by a fine of not more than $10,000 or

imprisonment of not more than five years, or both.

I hereby certify that the person with the disability listed above is under my care and has the following condition listed on the reverse side of this

application under “Eligibility Requirements”: _______________ (NOTE: Only those conditions listed on the reverse side of this application qualify an

applicant for a person with disability placard.)

List Reason Code # Here

NOTE: If reason code #4 is listed above, please indicate the type of device used: _________________________________________________

Temporary placards are only issued for a period of time not to exceed six months. If the applicant requires additional time after the expiration of the

placard issued, the applicant must be recertified by a health care provider.

Health Care Provider’s Name

Health Care Provider’s Signature

Medical License No.

FOR TEMPORARY PLACARD ONLY: Please

circle expiry needed - not to exceed 6 months

from certification date.

Office Street Address

City

State

Zip Code

Mar

Jun

Sept

Dec

CERTIFICATION BY POLICE OFFICER - Police officer may only certify that the applicant does not have full use of a leg or both legs, or is blind.

NOTE: If Section B above is completed, please skip this Section and go on to Section E.

This is to certify that the person with disability listed above has the condition listed and is entitled to the use and privileges of the person with disability

is blind,

does not have full use of a leg or both legs as evidenced by the use of a

parking placard.

wheelchair

walker

crutches

cane/quad cane

other prescribed device

Officer’s Name

Officer’s Signature

Badge Number

Office Street Address