Form Dpsmv 1966 - Medical Examiner'S Certification Of Mobility Impairment Form
Download a blank fillable Form Dpsmv 1966 - Medical Examiner'S Certification Of Mobility Impairment Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Dpsmv 1966 - Medical Examiner'S Certification Of Mobility Impairment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1MEDICAL EXAMINER'S CERTIFICATION OF MOBILITY IMPAIRMENT
I certify that (Name)_______________________________________________
Birth Date: ____________________
(Address) _______________________________________________________
Race/Sex: _____________________
meets the requirements as outlined in #________________ (listed at the bottom) and qualifies for a mobility impaired license
plate/hang-tag. I further understand that willful and false certification shall subject me to fines/imprisonment as outlined in R.S.
47:463.4 (G)(4).
PERMANENTLY IMPAIRED (Applicant has a total or
TEMPORARILY IMPAIRED (Applicant has a temporary
lifelong condition of mobility impairment from which little
condition of mobility impairment from which improvement
or no improvement or recovery can reasonably be expected.
or recovery can reasonably be expected. Applicant is
A medical examiner's certification is required on initial
entitled to a hang-tag which will be valid for one (1) year.
application only.)
A medical examiner's certification is required for renewal of
hang-tag.)
UNABLE TO APPEAR IN PERSON AT OFFICE OF
MOTOR VEHICLES (Applicant must bring small facial
photo.)
Medical Examiner's Signature
Date
Address
State License #
Telephone #
TO BE COMPLETED BY MV ANALYST ONLY
Vin ______________________________________________________________
Lic. Plate # ____________________
Hang-tag Control # __________________________________________________
Placard ID # ___________________
Date Issued _____________________
Operator # _____________________
Office # _______________________
LOUISIANA DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONS
OFFICE OF MOTOR VEHICLES
NOTICE
FAILURE TO SUBMIT MEDICAL EXAMINER'S CERTIFICATION OF MOBILITY IMPAIRMENT (SEE ABOVE) FOR MOBILITY
IMPAIRED LICENSE PLATE OR HANG-TAG WILL RESULT IN REJECTION AND/OR RETURN OF APPLICATION.
One (1) hang-tag allowed per person. Two (2) mobility impaired license plates allowed per person. HANG-TAG OR LICENSE
PLATE not to be issued/renewed to ANYONE other than the mobility impaired person or designee.
The term, "mobility impaired person", shall include any person who is impaired because of any of the following conditions:
1
Cannot walk two hundred feet without stopping to rest.
2
Cannot walk without the assistance of another person, walker, cane, crutches, braces, prosthetic device, or
wheelchair.
3
Is restricted by a lung disease to such an extent that 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 sixty mm/hg on room air at rest.
4
Uses portable oxygen.
5
Has a cardiac condition to the extent that the person's functional limitations are classified in severity as
Class III or Class IV according to standards by the American Heart Association.
6
Has a diagnosed disease or disorder, including a severe arthritic, neurological, or orthopedic impairment,
which creates a severe mobility limitation.
DPSMV 1966 (R 9/2001)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Ssa-787 - Physician's/medical Officer's Statement Of Patient's Capability To Manage Benefits
Legal
Form Mch-213 E - School Entrance Health Form - Health Information Form/comprehensive Physical Examination Report/certification Of Immunization
Legal
Form Hud-50059 - Owner's Certification Of Compliance With Hud's Tenant Eligibility And Rent Procedures
Business
Form 4c - Employee's Certificate Of Non-resident Allocation Of Withholding Tax - Kansas Department Of Revenue
Financial
Form 1120-ic-disc - Borrower's Certificate Of Compliance With The Rules For Producer's Loans
Financial
Related Categories
Parent category: Business