Fillable Form Ps-18-Disability Plates/placard Application printable pdf download

APPLICATION FOR DISABILITY PLATES/PLACARD

BMV ENTERED

 Disability Placard or  Disability Plate(s)

 Permanent Re-Issue

BMV Use Only

For Plates, please attach a copy of your current registration

_________________

Placard#

Applicant

_______________________

Name:

Mailing

_______________________

Address:

___________________

Plate #

________________

Issue Date:

________________

Exp. Date:

________________

Returned#:

DOB:

Driver’s License or ID # and Expiration Date:

________________

Replaced#:

Phone:

________________

Issued by:

State of Issue:

Contact Name:

Completed forms may be

processed at any BMV branch

Applicant’s Signature:

Date:

office or mailed/faxed to:

Bureau of Motor Vehicles

APPLICANT’S STATEMENT OF UNDERSTANDING

Disability Clerk

29 State House Station

I may park in a disability parking space when the vehicle is occupied by the disabled

Augusta, ME 04333-0029

person and the vehicle is properly displaying disability plates or a placard. I understand

permanent disability applications are valid until my current driver’s license or state ID card

TTY Users call Maine Relay 711

expires; if I want to continue my permanent disability parking credentials beyond that

FAX:

(207) 624-9204

expiration, I must complete the top portion of an application, mark it as Permanent Re-

Phone: (207) 624-9000

Issue and visit a BMV branch office or mail/fax it to the BMV main office.

Ext. 52149

MEDICAL PROVIDER’S STATEMENT

Condition is:

 Permanent

 Temporary for a period of _______ months (6 months maximum)

Please check one of the following conditions:

 Cannot walk two hundred feet without stopping to rest.

 Cannot walk without the use of, or assistance from another person or the use of a brace, cane, crutch, prosthetic

device, wheelchair, or other assistive device.

 Is restricted by lung disease to such an extent that the person’s forced expiratory volume for one second, when

measured by spirometry, is less than one liter, or the arterial oxygen tension is less than sixty m/hg on room air at rest.

 Uses portable oxygen.

 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 the standards set by the American Heart Association.

 Is severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition.

Is recovering from childbirth: TEMPORARY PLACARD ONLY - check appropriate box below

 Cesarean delivery – valid for 1 week following receipt of application;

 For the birth of a preterm infant, valid for ____________ (specify length of time, not to exceed 6 months)

Physician Physician’s Assistant

Nurse Practitioner

Registered Nurse

Medical Provider:

Printed Name:

Date:

Medical Lic #:

Signature:

Phone:

Fax #:

Address:

21-Day Temp # Issued:

PS-18 (Rev 06-12)

Form Ps-18-Disability Plates/placard Application

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