Form Reg3164 - Parking Placard Application For Persons With Disabilities - Government Of Alberta Page 2

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Section 2 A CERTIFIED MEDICAL PROFESSIONAL (physician, occupational therapist,
or physiotherapist) must complete this section.
ELIGIBILITY:
Persons unable to walk more than 50 metres (150 feet).
"
Walk" is defined as "progress by lifting and setting down each foot in turn, never having
both feet off the ground at once."
Source: The Concise Oxford Dictionary, 2001.
1.
Check ONE of the following boxes:
Short term disability where the applicant is unable to walk more than 50 metres (150 feet) for
three to twelve months.
Expected period of disability is
months.
Long term disability where the applicant is unable to walk more than 50 metres (150 feet) but the
disability may improve within the next 5 years, (e.g. no longer requires the use of a wheelchair).
The applicant will be required to re-apply in 5 years to determine their eligibility for a placard.
Explanation:
Permanent disability where the applicant is unable to walk more than 50 metres (150 feet) and
their disability is of a permanent nature and will not improve within the next 5 years (e.g. requires
the permanent use of a wheelchair). The applicant will be able to self-declare in 5 years to
renew their placard, and will not require verification from a certified medical professional.
Explanation:
2.
Describe the nature of the applicant's disability.
3.
Describe any limitations to the applicant's mobility.
4. Describe the type of aid or assistance used by the applicant, if applicable.
Wheelchair
Scooter
Other
(specify):
5
Would you recommend a complete medical report and/or a road test to assess the applicant's
.
ability to operate a motor vehicle?
Medical Report?
Yes
No
Road Test?
Yes
No
Telephone Number
Name of Certifying Medical Professional
(include area code)
Address
Street
City / Town
Province
Postal Code
Registration Number
Physician
Occupational Therapist
Physiotherapist
Professional Designation:
I understand that I may be asked to verify the applicant's disability in the event of misuse or abuse
of the privileges associated with the issuance of this parking placard.
Signature of Certifying Medical Professional
Date
REG3164 (2010/11)
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