Form Reg3164 - Parking Placard Application For Persons With Disabilities - Government Of Alberta
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Registry Agent Office use
only.
Please attach
PLACARD VALIDATION
Parking Placard
Registry Agent Office use only.
Application for
Please attach BAR CODE / NUMBER Label here.
Persons with
Disabilities
Check ONE only:
When the application has been approved by a
certified medical professional, it must be
First Time
presented to a registry agent within 6 months,
or a new application will have to be completed.
Renewal
Section 1 APPLICANT - Person to whom the parking placard will be issued.
NOTE:
A Legal Guardian/Parent or individual with Power of Attorney must sign when the applicant is
under age 18 or has a disability that prevents them from completing the application.
Name of Applicant
(Last, First, Second)
Date of Birth
year
month
day
Address
Telephone Number
Street
City /Town
Province
Postal Code
(include area code)
Are you a licensed driver?
Yes
No If yes, please give your Operator's Licence Number:
I, the applicant, acknowledge that:
• my condition, as verified in Section 2 by my certified medical professional is true;
• any misuse of a placard issued to me may result in the placard being cancelled, and
• if a placard is issued to me the information on my application may be provided to the
Driver Fitnessand Monitoring Branch to be cross-referenced against my driver's record,
and my primary care physician may be contacted.
• I am responsible for any costs related to completing this application.
Signature of Applicant
Date
Where applicable, the above statement regarding the applicant’s condition must be acknowledged
below by the signature of the Legal Guardian/Parent or individual with Power of Attorney.
Signature of Legal Guardian/Parent or
Name
Date
individual with Power of Attorney
For DFM use only
This information is being collected to administer the Parking Placards for Persons with Disabilities policy. The
information is governed by the Freedom of Information and Protection of Privacy Act. Questions about the
collection of this information can be directed to the Freedom of Information and Protection of Privacy Coordinator
for the Alberta Government, Box 3140, Edmonton, Alberta T5J 2G7, 780-427-7013.
3164201011
REG3164 (2010/11)
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