Form Sp-28 - Application For Temporary Disabled Persons Placards Nrs 482.383 printable pdf download

Form Sp-28 - Application For Temporary Disabled Persons Placards Nrs 482.383

555 WRIGHT WAY

CARSON CITY, NV 89711

(775) 684-4368 TOLL FREE (877) 368-7828

APPLICATION FOR TEMPORARY DISABLED PERSONS PLACARDS

NRS 482.383

Nevada law allows for issuance of one (1) or two (2) Disabled Persons Parking Placards to a person with a temporary

disability which impairs their ability to walk. A Temporary Disabled Persons Parking Placard may be issued for up to 6

months.

I wish to apply for:

One

Two

Temporary Disabled Persons Parking Placard(s)

Please Print or Type:

Applicant’s Name_________________________________________________ _____

_________________________

(Disabled Person)

LAST

FIRST

M.I.

DATE OF BIRTH

Address________________________________________________________ City

State____________________

Zip Code___________________Daytime Telephone No (____)_______________

County of Residence______________________________________________________________________________

Signature of Applicant______________________________________________________Date___________________

THIS PORTION MUST BE COMPLETED BY A LICENSED PHYSICIAN

As a Physician for the above-named patient, I hereby certify that the applicant has a TEMPORARY physical disability.

1. __________ Cannot walk two hundred feet without stopping to rest.

2. __________ Cannot walk without the use of a brace, cane, crutch, wheelchair, or other device, or another person.

3. __________ Is restricted by a lung disease.

4. __________ Uses portable oxygen.

5 __________ Has a cardiac condition to the extent that functional limitations are classified as a Class III or Class IV

according to standards adopted by the American Heart Association.

6. __________ Is visually handicapped.

7. __________ Is severely limited in his/her ability to walk because of an arthritic, neurological, or orthopedic condition

_____________________________________________________________

Estimated Period of Disability

Physician’s Name___________________________________________________________________________________

Mailing Address______________________________________________________________________________________

City______________________

State___________________

Zip Code____________

Physicians License Number______________________________

Telephone No

(

)

Physicians Signature______________________________________________________ Date____________________

SP-28 (Rev. 12-01)

Form Sp-28 - Application For Temporary Disabled Persons Placards Nrs 482.383

Related Articles

Related forms

Related Categories