Form Sp-41 Application For Vehicle License Plates And/or Placards For Persons With Disabilities New Jersey

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Special Plate Unit
PO Box 015
New Jersey
Trenton, NJ 08666-0015
(888) 486-3339
(NJ toll-free)
Motor Vehicle Commission
(609) 292-6500
(Out of state)
I.D. Card No: ________________ License Plate No: __________________ Placard No: ________________ Date Issued: ________________
(FOR COMMISSION USE ONLY: DO NOT WRITE ABOVE THIS LINE)
APPLICATION FOR VEHICLE LICENSE PLATES AND/OR PLACARDS FOR PERSONS WITH
DISABILITIES (PAGE 1 OF 2)
SECTION A: APPLICANT INFORMATION
THE APPLICANT MUST COMPLETE THIS SECTION BEFORE PHYSICIAN’S CERTIFICATION (SECTION B). TO AVOID DELAYS IN
PROCESSING PLEASE READ ALL INSTRUCTIONS CAREFULLY, TYPE OR LEGIBLY PRINT ALL ENTRIES, AND VISIT ANY
LOCAL MOTOR VEHICLE AGENCY WITH THE COMPLETED APPLICATION.
Name of Applicant: __________________________________________________________________________________________
Street Address: ______________________________________________________________________________________________
NJ RESIDENTS ONLY
City, State, Zip Code: _________________________________________________________________________________________
NJ RESIDENTS ONLY
Applicant’s Driver License Number: ___________________________________________________ OR
If Applicant does not have a current NJ Drivers License, please provide: Date of Birth: _________ Sex: ______ Eye Color: ______
Ht: _______ Wt: ________
I AM APPLYING FOR:
LICENSE PLATES
PLACARD (Complete Applicable Section Below)
Please Note: License plates and/or placards for eligible persons are issued with an Identification Card and are to be used
exclusively for and by the person named on the Identification Card.
LICENSE PLATES
: COMPLETE THIS SECTION IF APPLYING FOR LICENSE PLATES/ IDENTIFICATION CARD. WHEELCHAIR SYMBOL
LICENSE PLATES MAY BE ISSUED FOR ONE VEHICLE OWNED, OPERATED OR LEASED BY A PERSON WITH DISABILITIES OR FAMILY MEMBER
PROVIDING TRANSPORTATION FOR THAT PERSON. COMPLETE BELOW AND SEND A PHOTCOPY OF THE VEHICLE REGISTRATION:
Registered Owner of Vehicle
Current Plate No.
Expires
________________________________
_____________________
______________
Owners Driver License No._____________________________________________________________________________
Street Address________________________________________ City, State, Zip Code_____________________________
Relationship to the person with the disability:
Self
Parent
Guardian
Other ________________________
(Please Specify)
The license plates are to be used exclusively for the person named on the identification card. The identification card is non-
transferable and will be forfeited if used by any other person. Abuse of this privilege is cause for revocation of both the license
plates and identification card and possible criminal sanctions.
I CERTIFY, UNDER PENALTY OF LAW, THAT THE STATEMENTS ON THIS APPLICATION ARE TRUE.
Registered Owner’s Signature: _________________________________________________________________________
Applicant’s Signature: ______________________________________________________________ Date: ___________
PLACARD:
COMPLETE THIS SECTON IF APPLYING FOR A PLACARD/ IDENTIFICATION CARD
NEW
REPLACEMENT (OLD PLACARD # ________________ IF KNOWN. TO REPLACE PLACARD AND ID CARD, ATTACH
NOTARIZED STATEMENT ATTESTING THAT BOTH ORIGINAL PLACARD AND ID CARD WERE LOST.)
The placard must be displayed on the rearview mirror of the vehicle whenever such vehicle is parked in a designated handicapped
symbol parking space and must be removed when the vehicle is in motion.
The placard is for the exclusive use of the person named on the identification card. The identification card is non-transferable and
will be forfeited if used by any other person. Abuse of this privilege is cause for revocation of the both the placard and identification
card and possible criminal sanctions. The placard expires in three (3) years and must be renewed and that upon receipt of the renewal
application, under law, the Motor Vehicle Commission may request recertifying qualifications from a physician.
I CERTIFY, UNDER PENALTY OF LAW, THAT THE STATEMENTS ON THIS APPLICATION ARE TRUE.
Applicant’s Signature: _____________________________________________________________ Date: ___________
SP-41 (R3/09)

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