Fillable Physical Disability Parking Placard Application Form printable pdf download

Department of Public Safety

Physical Disability Parking Placard Application

Driver Compliance Division

The Department of Public Safety requires approximately 20 business days after receipt to process the application.

This form must be completed by applicant (patient) and physician before a disability placard can be issued.

I hereby make application to the Department of Public Safety for a physical disability parking placard. I understand I must display the

official placard on the rearview mirror of my vehicle. I further understand this item may only be displayed in motor vehicles either operated

by me, or in which I am a passenger. I understand that any person who knowingly makes false application for, or unauthorized use of,

the placard is guilty of a misdemeanor and upon conviction thereof shall be punished by a fine of $500 .

___________________________________________________________________________________________________________________

Please print or type

Applicant (patient) name: ___________________________________________________________ Date of birth: __________________

(First)

(Middle)

(Last)

Mailing address: __________________________________________________________________________________________________

(Street or P.O. box)

(City)

(State)

(Zip)

____________________________________________________________

Driver license/ID number:

Phone: ________________________

(Home)

NOTICE: I understand that by signing and submitting this form, my ability to operate a motor vehicle may be reviewed

as provided in 47 O.S. § 6-119, pursuant to the standards prescribed by the Driver License Medical Advisory

Committee as created in 47 O.S., § 6-118.

Signature (required): __________________________________________________________________

The Department shall only consider applications submitted within sixty (60) days of the date of the physicians signature.

______________________________________________________________________________________

The following section must be completed by a physician licensed to practice medicine or surgery, osteopathic medicine, chiropractic,

podiatric medicine, or optometry; a licensed physician assistant; or a licensed and certified advanced registered nurse practioner.

The above-named applicant (patient):



A. Cannot walk 200 feet without stopping to rest, or

E. Has functional limitations which are classified in severity as Class

III or Class IV according to standards set by the American Heart

Association, or



B. Cannot walk without the use of or assistance from a brace, cane,

F. Is severely limited in his or her ability to walk due to an arthritic

crutch, another person, prosthetic device, wheelchair or other

neurological, or orthopedic condition, or complications due to

assistant device, or

pregnancy, or



C. Is restricted to such an extent that the person’s forced (respiratory)

G. Is certified legally blind, or

expiratory volume for one liter, or the arterial oxygen tension is less

than 60MM/HG on room air at rest, or



D. Must use portable oxygen, or

H. Is missing one or more limbs which impairs mobility.

In your professional opinion would this condition affect this person’s ability to safely operate a motor vehicle under

normal or adverse driving conditions?



Yes

Diagnosis: _______________________________________________________________________________

Type of placard requested:

_____ 5-YEAR PLACARD

TEMPORARY ISSUED

_____ TEMPORARY PLACARD

EXPIRATION DATE: _________________

FOR UP TO 6 MONTHS

I certify that the applicant’s (patient’s) physical disability described above is accurate, and the care and treatment is within the authorized scope of my practice.

Date: ______________ Physician’s name: _____________________________________ Physician’s license no. _____________________

Please print or type

Address: __________________________________________________________________________________________________________

(Street or P.O. Box)

(City)

(State)

Phone: ___________________________ Physician’s signature: ______________________________________________________________

Must indicate type of placard and provide all information, not just signature.

______________________________________________________________________________________

FOR DPS OFFICE ONLY

Expiration date:______________________________ Date issued:________________________ Placard number: __________________________________

______________________________________________________________________________________

Mail this completed application to:

If you have any questions, please call (405) 425-2290.

Department of Public Safety

Driver Compliance Div. - Physical Disability

P.O. Box 11415

Oklahoma City, OK 73136-0415

DPS 302DC 002 07/2011

Physical Disability Parking Placard Application Form

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