Form Sp-41 Application For Vehicle License Plates And/or Placards For Persons With Disabilities New Jersey Page 2
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1
2APPLICATION FOR VEHICLE LICENSE PLATES AND/OR PLACARDS FOR PERSONS WITH
DISABILITIES (PAGE 2 OF 2)
I.D. Card No: ________________ License Plate No: __________________ Placard No: ________________ Date Issued: ________________
(FOR COMMISSION USE ONLY: DO NOT WRITE ABOVE THIS LINE)
Applicant Name (print)_______________________________________________________________________________________
SECTION B: PHYSICIAN’S CERTIFICATION
THE FOLLOWING MUST BE COMPLETED AND CERTIFIED BY A MEDICAL DOCTOR, PODIATRIST OR
CHIROPRACTOR WHO IS LICENSED TO PRACTICE IN NEW JERSEY (OR A BORDERING STATE):
By law, eligibility for license plates and/or placards for persons with disabilities is limited to the following conditions. (NO OTHER
PERSON IS ELIGIBLE FOR LICENSE PLATES OR PLACARDS). Please check the most appropriate box/boxes.
The applicant:
1. Has lost the use of one or more limbs as a consequence of paralysis, amputation, or other permanent disability
2. Is severely and permanently disabled and cannot walk without the use of or assistance from a brace, cane, crutch, another
person, prosthetic device, wheelchair or other assistive device.
3. Suffers from lung disease to such an extent that the applicant’s forced (respiratory) expiratory volume for one second,
when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than sixth mm/hg on room air at
rest; or uses portable oxygen.
4. Has a cardiac condition of the extent that the applicant’s functional limitations are classified in severity as Class III or
Class IV according to standards set by the American Heart Association.
5. Is severely and permanently limited in the ability to walk because of an arthritic, neurological, or orthopedic condition; or
cannot walk two hundred feet without stopping to rest.
6. Has a permanent sight impairment of both eyes as certified by the N.J. Commission of the Blind (Placard only).
Under New Jersey law (N.J.S.A. 2C:21-4a), making a false statement or providing misinformation on an application to obtain or
facilitate the receipt of license plates or placards for persons with disabilities is a fourth degree crime and a person who has been
convicted of this offense may be subject to pay a fine not to exceed $10,000 and a term of imprisonment of up to 18 months.
I certify and attest, under penalty of law, that _______________________________________ has appeared before me and
(Print Applicant’s Name)
meets the eligibility criteria as specified in box number(s) ______ (checked above) and thus meets the requirements for the
receipt of license plates and/or placards for persons with disabilities.
Signature of Physician __________________________________________________ Date______________
PLEASE TYPE OR PRINT: PHYSICIAN NAME, LICENSE NUMBER, ADDRESS AND TELEPHONE NUMBER
___________________________________________________________
_____________________________
(Physician’s Name)
(Date)
___________________________________________________________
(License Number/State)
___________________________________________________________
(Street Address)
___________________________________________________________
______________________________
(City, State and Zip)
(Telephone Number)
(Please Note: If the above information is not clearly legible it may result in delays in applicant receiving plates and/or placard).
____________________________________________________
IMPORTANT NOTICE
Plates must be renewed every year and placards must be renewed every three years. Upon receipt of an
application for renewal the Motor Vehicle Commission may require the applicant to submit a statement from a
physician recertifying his/her qualification as provided under N.J.A.C. 13:20-9.1(a) 4.
SP-41 (R3/09)
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