Application For Handicap Parking Permit (Page 3 of 4) in pdf

New York State Department of Motor Vehicles

Please

TEAR

PERF

at the

APPLICATION FOR A PARKING PERMIT OR LICENSE PLATES,

and keep pages 1 & 2

FOR PERSONS WITH SEVERE DISABILITIES

for your information.

Please read pages 1 and 2 of this packet before you complete this application. If you apply for a parking permit, take the completed application

to the issuing agent (local municipality) in the city, town or village where you live;

do not send your application to the Department of

Motor Vehicles because DMV does not issue parking permits.

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 want:

License Plates (Apply to DMV.)

A Parking Permit (Apply to your local issuing agent.)

Male

Female

Do you have license plates for persons with disabilities?

Yes - My license plate number is:__________________

Read note on page 4 before you sign

If signed by a parent or guardian,

(Date)

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

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

Part 2 MEDICAL CERTIFICATION

NOTE: PERMANENT DISABILITIES may be certified by a Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA),

Nurse Practitioner (NP), a Doctor of Podiatric Medicine (DPM, for disabilities related to the foot) or Optometrist (OD, for blindness).

, however, may be certified only by a Medical Doctor or Doctor of Osteopathy.

TEMPORARY DISABILITIES

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. Examples of an assisting device include, but are not limited to, a brace, cane, crutch, prosthetic device, another person,

wheelchair or walker.

Temporary permits are issued for six months or less regardless of expected recovery date.

IMPORTANT:

______________________

_____________________________________________________

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.

___________________________________________________ Please

Diagnosis:_

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 BELOW HOW THIS DISABILITY LIMITS FUNCTIONAL MOBILITY.

___________________________________________________________________________________________________________

MD/DO/DPM/NP/PA/OD Name

Professional License No.

MD/DO/DPM/NP/PA/OD Address

Telephone No.

(

)

Read note on page 4 before you sign

(MD/DO/DPM/NP/PA/OD Signature)

(Date)

Part 3 FILE INFORMATION

(For Issuing Agent Use Only)

Blue

Red Parking Permit No. __________________ Date Issued:_______________ Date Expires:_____________________

First

Second

9-digit number from NYS Driver License/ID Card ______________________________

Denied

Revoked Reason:________________________________________________________________

_________________

(Date)

___________________________________________________________________________________

(Issuing Agent)

(Locality)

PAGE 3 OF 4

MV-664.1 (2/14)

Application For Handicap Parking Permit Page 3

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