Application For Accessible Parking Placard
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~APPLICATION
FOR ACCESSIBLE
PARKING
PLACARD
—
DEPARTMENTOF REVENUE AND TAXATION VEHICLE REGISTRATION BRANCH
HOURS
OF
OPERATION:
8:00AM
-
4:00PM
M-F
PLEASE NOTE:
1)
Applicants must provide identification
(Guam I.D., Naturalization Certification, Green Card, Firearms
I.D., etc.)
2)
Upon renewal of a temporary placard, applicant must obtain another certification from a physician.
NAME:
SOCIAL SECURITY NO.
_______________________________
__________________________________________________________________________________________________
(LAST)
(NAME)
(INT.)
MAILING ADDRESS: __________________________________________
___________________
(STREET NUMBERIP.O.BOX)
ZIP CODE
HEIGHT:
WEIGHT:
SEX:
DATE OF BIRTH:
PHONE NO.:
_______
__________
_________
_______
_______________
1.
Do you have a current accessible parking placard?
Yes____ No
If yes, Placard No(s):
____
________________________
Expiration Date:
________________
2.
Do you have a current accessible parking license plate?
Yes____ No
If yes, License Plate Number:
____
____________
Expiration Date:
_______________
I
3.
Please check the appropriate box:
Placard(s)
License Plate
[
I ]
the foregoing is true and correct.
I declare under penalty of perjury that
the release of medical information to process this application.
I authorize
APPLICANT’ S SIGNATURE:
DATE
_________________________
_____________
PHYSICIAN’S CERTIFICATION
Section 1. Purpose. The purposes of this act are to establish a uniform system for accessible parking for persons with disabilities to enhance
walk, and to conform to the requirements of
access and the safety of persons who have disabilities, which limit or impair the ability to
the
Americans with Disabilities Act. Accessibility Guidelines as they apply to accessible parking.
LOSS OF USE OF LOWER LIMBS (5):
Condition:
Amputation
Birth Defect
Special Equipment
Artificial Limb(s)
)Braces
( )
( )
( )
(
Multiple Sclerosis
Muscular
Cane(s)
)Crutch(es)
( )
( )
( )
(
Wheel Chair
Paraplegic
Dystrophy
Walker
( )
( )
( )
( )
Other
Other
Polio
( )
)
( )
_________(
______________________
RESPIRATORY CONDITION:
Is restricted by lung disease to such an extent that the person’s forced (respiratory) expiatory volume for one second, when
measured by spirometry, is less than one liter, or the arterial oxygen tension is less than sixty (60) mm/hg on room air at rest.
EYE(s) CONDITION:
I
Has a central visual acuity that does not exceed 20/200 in the better eye, with corrective lens, as measured by the Snellen Test, or
visual activity greater than 20/200, but with a limitation in the field of vision such that the widest diameter of the visual field subtends an
angle not greater than 20 degrees.
HEART CONDITION CLASSIFICATION: (By the standards set by the American Heart Association)
Class III
Class IV
[ ]
OTHER DIAGNOSES DISEASED OR DISORDER, WHICH CREATES A SEVERE WALKING MOBILITY LIMITATION (cannot walk
two hundred feet (200’) without stopping to rest due to):
Arthritic
Neurological
Orthopedic
Other
I ]
I ]
I ]
______________________________
I, the undersigned, being duly licensed to practice in Guam, certify under the penalties of perjury that I am personally aware of the degree of
impaired mobility of the person identified in this application as indicated above. It is my professional opinion that this applicant should
qualify for the issuance of the special Parking Placard having a condition due to the significant physical mobility limitations and/or for the
safety of the applicant.
APPROVED-PERMANENT DISABILITY
[]
APPROVED-(TEMPORARY DISABILITY)
NOT TO EXCEED SIX (6) MONTHS
[]
DISAPPROVED (MOBILITY IS NOT AFFECTED BY CONDITIONS(S):
[]
_____________________________
Physician’s Signature
Print Name
Clinic
Address/Telephone
FOR OFFICIAL USE BY DEPARTMENT OF REVENUE AND TAXATION
VEHICLE REGISTRATION BRANCH
[INEW
RENEWAL
REPL.PLACARD NO.
EXP. DATE:
PREVIOUS PLACARD NO.
I ]
I]
_____
________
COMMENTS:
(Rev3/04)
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