STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
DIVISION OF MOTORIST SERVICES
APPLICATION FOR A DISABLED, DISABLED VETERAN OR MOTORCYCLE
INTERNATIONAL WHEELCHAIR SYMBOL LICENSE PLATE
***** SUBMIT APPLICATION TO YOUR LOCAL COUNTY TAX COLLECTOR’S OFFICE OR LICENSE PLATE AGENCY *****
I, ___________________________________________________________, certify that I am a legal resident of Florida residing at
and I am the registered
Lessee of the following described motor vehicle:
Vehicle Identification Number
Florida Title Number
Owner/Lessee Date of Birth
Current License Plate Number
Owner/Lessee E-Mail Address
Florida Driver License or Identification Number: _______________________________________________________________________
I certify that I qualify for the wheelchair symbol license plate as defined in sections 320.0842, 320.0843 or 320.0848, Florida
Statutes, and I have obtained the appropriate physician/certifying practitioner’s certification.
Disabled wheelchair license plate
Disabled Veteran (DV) Wheelchair license plate
Disabled Motorcycle wheelchair license plate
SIGNATURE – DISABLED PERSON/VETERAN
PHYSICIAN/CERTIFYING PRACTITIONER’S STATEMENT OF CERTIFICATION
For Disabled Person to Obtain a Regular or Motorcycle Size Wheelchair Symbol License Plate
This is to certify that ____________________________________________________________ is legally blind or is a disabled person with a specific
disability (ies) that limits or impairs his/her ability to walk 200 feet without stopping to rest. The specific disability (ies) is/are checked below:
Legally blind (This is the only disability an Optometrist can certify)
* * * NOTE: "Unable to walk 200 feet" is no longer a qualifying disability, unless it is due to one of the conditions listed below (a-f). * * *
Inability to walk without the use of or assistance from a brace, cane, crutch, prosthetic device, or other assistive device, or without
assistance of another person. If the assistive device significantly restores the person’s ability to walk to the extent that the person can
walk without severe limitation, the person is not eligible for the exemption parking permit or the wheelchair symbol license plate.
b. The need to permanently use a wheelchair.
Restriction by lung disease to the extent that the person’s forced (respiratory) expiratory volume for 1 second, when measured by
spirometry, is less than one liter or the persons arterial oxygen is less than 60 mm/hg on room air at rest.
Use of portable oxygen
Restriction by cardiac condition to the extent that the person’s functional limitations are classified in severity as Class III or Class IV
according to standards set by the American Heart Association.
Severe limitation in a person’s ability to walk due to an arthritic, neurological, or orthopedic condition.
Print/Type Name of Certifying Authority
Business Street Address
(Area Code) Telephone Number
Certification or License No. (Required)
of Physician, Osteopathic or Podiatric Physician, Chiropractor, Optometrist,
Advanced Registered Nurse Practitioner under the protocol of a licensed physician or a Physician Assistant licensed under Chapter 458 or 459.
LICENSED IN THE STATE OF: _______________________________
WARNING: Any person who knowingly makes a false or misleading statement in an application or certification under section 320.0848,
Florida Statutes, commits a misdemeanor of the first degree, punishable as provided in section 775.082 or 775.083, Florida
Statutes. The penalty is up to one year in jail or a fine of $1,000 or both.
Check your local phone book government pages or visit the following website for current mailing addresses:
HSMV 83007 (Rev. 02/13)