Application For Special Parking Permit Or License Plates For A Physically Disabled Person Form 2000 printable pdf download

DEPARTMENT USE ONLY

STATE OF MONTANA

APPLICATION FOR SPECIAL PARKING PERMIT or

Expiration Date:

LICENSE PLATES FOR A PHYSICALLY DISABLED PERSON

Permit Number(s):

THIS PART MUST BE COMPLETED BY THE APPLICANT (please print):

Name of Applicant:

(one applicant per form)

Address:

City or Town:

Mailing Address:

Zip Code:

I understand that I am eligible for one special parking permit and/or one set of license plates for each non-commercial motor

vehicle that I own and that if I do not own a motor vehicle, I may only receive a single special parking permit. I am applying

for the following type and quantity of permit(s) and/or sets of license plates (please specify number required if more than one

permit and/or set of plates is sought): THERE IS NO FEE FOR THIS PERMIT(S).

Replacement Permits

Special License Plates

Date:

Applicant's signature:

NOTICE CONCERNING RELEASE OF PERSONAL INFORMATION

Motor vehicle records are released to individuals and businesses for a variety of uses, BUT you may have your name and address withheld from release

for certain uses by INITIALING (void if any other mark is used) the appropriate box(es) below. Your selection(s) will not affect release for motor vehicle

recall, warranty, anti-theft, safety or emission purposes. Selection applies to personal information of any co-owner for this vehicle record. To cover other

vehicle records, you must obtain a separate form at your county treasurer's office.

No release for DIRECT

No release for OTHER USES, EXCLUDING governmental, business

initials

MAIL/PRODUCT

or employment verification, legal proceedings, licensed investigations,

only -->

MARKETING uses

insurance, towing or other statistical reporting purposes.

THIS PART MUST BE COMPLETED BY A LICENSED PHYSICIAN, CHIROPRACTOR OR NURSE PRACTITIONER:

PLEASE NOTE: Under Montana law, a special parking permit or license plate may only be issued to a person whose

mobility is limited or impaired by a disability and whose condition, as determined by a licensed physician or licensed

chiropractor, meets specified criteria.

Please check which conditions, if any, apply to the above-named applicant:

cannot walk 200 feet without stopping to rest;

is severely limited in ability to walk because of an arthritic, neurological, or orthopedic condition;

is so severely disabled that the person cannot walk without the use of or assistance from a brace, cane, another

person, prosthetic device, wheelchair, or other assistive device;

uses portable oxygen;

is restricted by lung disease to the extent that forced expiratory respiratory volume, when measured by spirometry,

is less than 1 liter per second or the arterial oxygen tension is less than 60 mm/hg on room air at rest;

has impairment because of cardiovascular disease or a cardiac condition to the extent that the person's functional

limitations are classified as class III or IV under standards accepted by the American Heart Association; or

has a disability resulting from an acute sensitivity to automobile emissions or from another disease or physical

condition that limits or impairs the person's mobility and that is documented by the licensed physician or licensed

chiropractor as being comparable in severity to the other conditions listed above.

Please check which term best describes the expected duration of the condition:

Permanent (limited or no improvement expected)

Temporary (improvement expected within six months)

Extended Temporary (improvement not achieved within initial six month period, but expected within an additional

period of ______ months [please specify], not exceeding 24).

PHYSICIAN, CHIROPRACTOR OR NURSE PRACTITIONER INFORMATION: (please type or print clearly)

PHYSICIAN/CHIROPRACTOR/NURSE PRACTITIONER PRINTED NAME

TYPE OF PHYSICIAN

PROFESSIONAL LICENSE NUMBER

PHYSICIAN/CHIROPRACTOR/NURSE PRACTITIONER ADDRESS

CITY

STATE

ZIP CODE

PHYSICIAN/CHIROPRACTOR/NURSE PRACTITIONER SIGNATURE

DATE

TELEPHONE NUMBER

-> X

Upon request, this form can be made available in an alternative format.

MV5 (09/00)

Application For Special Parking Permit Or License Plates For A Physically Disabled Person Form 2000

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