REVISED 3/14 (REVIEWED 3/15)
Applicant MUST Enter SSN Below
West Virginia Department of Transportation
Division of Motor Vehicles
DMV Completes Placard Detail Below
Parking Application for a Mobility Impaired Person
Mail to: Mobility Impaired Placards & Plates • PO Box 17010 • Charleston, WV 25317
Questions: 1-800-642-9066 •
PART I •
TO BE COMPLETED BY THE APPLICANT
(You must follow the Instructions provided on the back of this form.)
A.) Applicant Information •
DO NOT FORGET TO ENTER YOUR SOCIAL SECURITY NUMBER IN THE LIGHT GRAY BOX ABOVE.
B.) Plate and/or Placard Information •
License plates can only be issued to an applicant whose name appears on the WV vehicle registration.
Request for a Mobility Impaired Plate
Request for a Mobility Impaired Placard
Is this request due to a
Is this request due to a
Please list the lost or stolen plate number: ____________________
Please list the lost or stolen placard number: ____________________
C.) Vehicle and Insurance Information •
This section is only required to be completed if this request is for a license plate.
I certify that I am a person with a mobility impairment which limits or impairs my ability to walk and that all of the information above is accurate. I understand
that any false statement may result in legal penalties pursuant to West Virginia Code §17C-13-6. A parent or legal guardian may sign for the applicant if the is
unable to do so. Please note your relationship to the applicant.
SIGNATURE OF APPLICANT OR SIGNATURE OF LEGAL GUARDIAN AND RELATIONSHIP TO THE APPLICANT
PART II •
TO BE COMPLETED ONLY BY A LICENSED PHYSICIAN
Type of Condition:
Permanent • Valid for 1-5 Years
Temporary • Valid for Six Months
Patient cannot walk 200 feet without stopping to rest.
Patient cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair or other assisted device.
Patient is restricted by lung disease to such an extent the person’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 60mm/hg on room air at rest.
Patient uses portable oxygen.
IV according to standards set by The American
Patient is severely limited in their ability to walk due to arthritic, neurological, or orthopedic condition.
COMPLETE ALL OF PART II. FAILURE TO DO SO WILL RESULT IN THIS FORM BEING RETURNED TO THE SENDER FOR COMPLETION. ALL PHYSICIAN’S SIGNATURES AND
LICENSE’S ARE SUBJECT TO REVIEW FOR VERIFICATION. PHYSICIANS MAY BE REQUIRED TO SUBMIT FURTHER DOCUMENTATION TO SUBSTANTIATE THE DISABILITY.
(Please print in ink or type)