Form Sp-41 - Application For Vehicle License Plates And/or Placard For Persons With A Disability - New Jersey
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1
2Special Plate Unit
P.O. Box 015
Trenton, New Jersey 08666-0015
888-486-3339 (NJ Toll Free)
609-292-6500 (Out-of-State)
STATE OF NEW JERSEY
License Plate No: ______________________ Placard No: _____________________ Date Issued: __________________ Employee’s Initials: ________________
(FOR COMMISSION USE ONLY: DO NOT WRITE ABOVE THIS LINE)
APPLICATION FOR VEHICLE LICENSE PLATES AND/OR PLACARD FOR
PERSONS WITH A DISABILITY
THIS IS MY:
INITIAL APPLICATION
RECERTIFICATION APPLICATION
REPLACEMENT APPLICATION
I AM APPLYING FOR:
LICENSE PLATES
PLACARD
BOTH
SECTION A: PERSON WITH A DISABILITY IDENTIFICATION CARD INFORMATION
Name of Person with a Disability: ____________________________________________________________________
Street Address: __________________________________________________________________________________
City, State, Zip Code: _____________________________________________________________________________
Driver’s License Number: ____________________________________________ Expires _______________________
Date of Birth: __________________ Sex: ________ Eye Color: ____________Ht: _____________ Wt: ____________
I acknowledge that I hold a Commercial Driver License (CDL) and that this application may result in a medical review
which could result in a decision that may affect my New Jersey CDL privilege.
Current Plate Number: __________________ Current Placard Number: _________________ (for recertification applications)
SECTION B: WHEELCHAIR SYMBOL LICENSE PLATES
(photocopy of registration required)
Registered Vehicle Owner’s Name_____________________________ Vehicle Plate No._______________ Expires________
Registered Vehicle Owner’s Driver License Number___________________________________ Expires _______________
Street Address________________________________________ City, State, Zip Code_____________________________
Relationship to the Disabled Applicant:
Spouse
Parent
Guardian
Self
Other (Please Specify) ________________
SECTION C: REPLACEMENT PLATES, PLACARD AND/OR IDENTIFICATION CARD
LICENSE PLATES
PLACARD
IDENTIFICATION CARD
Vehicle Plate Number__________________ Expires_________ Placard Number__________________ Expires__________
Check one:
Lost– attach notarized statement of loss.
Damaged – return (plate(s), placard and/or ID card).
Stolen – plate(s), placard – attach police report.
SECTION D: CERTIFICATION OF STATEMENTS
I CERTIFY, UNDER PENALTY OF LAW, THAT THE STATEMENTS ON THIS APPLICATION ARE TRUE.
Signature of Registered Vehicle Owner: ________________________________________________Date:___________
Signature of Person with a Disability: __________________________________________________Date:
___________
SECTION E – MEDICAL PRACTITIONER’S CERTIFICATION & SECTION F - TERMS AND CONDITIONS
(on page 2)
SP-41 (R7/13)
Page | 1 of 2
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