Application For Disabled Parking Placard/plate
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2MASSACHUSETTS REGISTRY OF MOTOR VEHICLES
Medical Affairs Branch • P.O. Box 55889 • Boston, MA • 02205-5889 • (617) 351-9222
For Hand Deliveries: 25 Newport Avenue Extension, Quincy, MA
APPLICATION FOR DISABLED PARKING PLACARD/PLATE
THIS SIDE OF THE APPLICATION MUST BE COMPLETED IN THE DISABLED PERSON’S NAME
Disabled person must be a Massachusetts resident. Please note the information required in this application may affect your license status.
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Incomplete applications will not be processed.
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Both disabled person and medical professional signatures are required.
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This application must be submitted to the RMV within thirty (30) days of the healthcare provider's certification.
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Additional documentation may be required.
REPORT OF CERTAIN MEDICAL CONDITIONS MAY RESULT IN LOSS OF LICENSE
A. Disabled person's information (please print)
________________________________________________________________________________________________
Last Name
First Name
Middle
Gender
________________________________________________________________________________________________
Address
City/Town
Zip Code
____________________________________________________________________________
Date of Birth
Social Security Number (SSN)
Height
Telephone Number
_____________________________________________________________________________________________________________
Driver's License Number or Mass I.D. Number
B. Is this the first time you have submitted an application for a disabled parking placard/plate?
Yes
No - Please print your current disabled parking placard or plate number___________________________
C. I am applying for the following:
Placard
No fee required for a placard.
Plate
Only issued to individuals who have a vehicle registered in his/her name. Registration fees apply.
Motorcycle Plate
Only issued to individuals who have a vehicle registered in his/her name. Registration fees apply.
DV Plate
Only issued to individuals who a) have a vehicle registered in their name; b) meet Medical Affairs
guidelines; c) provide the DV Plate letter from the Veteran's Administration stating that the disability
is at least 60% service connected.
D. Important Information – PLEASE READ
It is illegal . . .
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To allow someone to use your placard, if you are not in the vehicle.
To forge a doctor’s signature.
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For an individual to have more than one permanent placard.
To provide false information (Persons can be
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To provide false information to obtain a placard or disabled person plates.
prosecuted under Massachusetts law.)
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To possess or display a counterfeit placard.
To alter a placard.
E. Applicant’s signature and certification
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I have read the “Important Information” in section “D” and fully understand and take responsibility for the use of the disabled
placard or plates that are issued to me.
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I certify under the pains and penalties of perjury that all the information provided in this application, including the representation of
my medical status/condition, is true and correct to the best of my knowledge.
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AUTHORIZATION TO RELEASE MEDICAL RECORDS - I hereby authorize the healthcare provider completing this form to
discuss and release any or all medical records pertaining to its content with or to representatives of the Registry of Motor Vehicles.
______________________________________________________
_________________________________
Signature of disabled person (REQUIRED)
Date
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