Form Pa 2 - Person With A Disability Parking Permit Application
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2PERSON WITH A DISABILITY PARKING PERMIT APPLICATION
FOR OFFICIAL USE ONLY
STATE OF HAWAII
1st Placard # _________________
DISABILITY AND COMMUNICATION ACCESS BOARD
2nd Placard # _________________
Expiration Date _______________
Applicant must present proof of identity.
All forms of identification must be current or unexpired.
Acceptable forms of identification include: drivers license, state ID, passport, senior citizen ID,
License Plates # _________________
military ID, student ID, ID of a parent or guardian of a minor, Medicare card; notarized affidavit from:
a Hawaii State or county social service agency, the administrator of a Hawaii State or privately
FEES COLLECTED, IF APPLICABLE:
owned nursing home, the spouse, an adult relative, a friend, an assistant, or the verifying physician.
Amount Collected $ ________
___________________________
Clerk’s Initials
Date
1. APPLICANT’S NAME
0000000000000000000000000
CLEAR FORM
LAST
00000000000000000000
00
FIRST
M.I.
0000000000
00
00
0000
/
/
2. PHONE NO
3. BIRTH DATE
.
(00 / 00 / 0000)
MONTH
DAY
YEAR
00
00
000
4. HEIGHT
5. WEIGHT
6. GENDER
Male
Female
/
FEET
INCHES
POUNDS
7. STREET ADDRESS
000000000000000000000000000000
STREET
000000
APT.#
000000000000000 00 00000-0000
CITY
STATE
ZIP CODE
8. MAILING ADDRESS
000000000000000000000000000000
STREET
000000
APT.#
000000000000000 00 00000-0000
CITY
STATE
ZIP CODE
9. INDICATE THE COUNTY WHERE YOU LIVE
City & County of Honolulu
County of Hawaii
County of Kauai
County of Maui
10. PARKING PLACARD REQUEST (Switching from a temporary placard to a permanent placard is considered a first time application)
Mark applicable box and enter serial number of placard(s) last issued. I am requesting a:
First Time Hawaii placard
0000000
0000000
;
Renewal of my Hawaii placard(s)
placard #(s)
0000000
0000000
;
Replacement
placard #(s)
11. COMPLETE ONLY IF REQUESTING SPECIAL LICENSE PLATES (Applying for a special plate cannot be done by mail)
I am requesting special license plates. I am the registered owner of the vehicle on which the special license plates will be affixed,
AND the vehicle will be used primarily to transport me.
0000
0000000000
0000000000
Year of Vehicle
Make
Model
000000
00
00
Vehicle Lic. #
Registration Expiration Date
/
(Month)
(Year)
12. TERMS TO RELEASE OF MEDICAL INFORMATION
I declare, under the penalties of the penal law, that the statements contained herein are, to the best of my knowledge and belief, true and
accurate and that I have not knowingly and willingly made a false statement or given information which I know to be false in connection
therewith. I also authorize my physician to release medical information necessary to process this application.
____________________
___________________________________________
APPLICANT’S SIGNATURE (or Authorized Representative)
DATE
PA 2
SIDE 1
July 2011
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