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

Application For Handicap Parking Permit Page 4

NOTE TO CUSTOMERS AND MEDICAL PROFESSIONALS

According to the NYS Vehicle and Traffic Law and the Penal Law, it is a crime (a felony or a

misdemeanor) to make a false statement or to provide false information on an application for a

parking permit or license plates for a person with severe disabilities. This crime is punishable by

a fine, imprisonment, or both. If this crime involves an application for a parking permit, the

crime may also result in liability for payment of a civil penality of $250 - $1,000.

For Customers Who Want License Plates, or a Parking Permit, for Persons with a Disability:

When you sign Part 1 of this application, you certify:

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 page 2; and

that you agree to comply with those conditions.

For Medical Professionals Who Provide Medical Information in Support of an Application for

License Plates, or a Parking Permit, for Persons with a Disability:

When you sign Part 2 of this application, you certify:

that the medical information you provide 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.

MV-664.1 (2/14)

PAGE 4 OF 4

Application For Handicap Parking Permit Page 4