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SECTION 2 - CONTINUED

B. I am qualified to receive a Disability Placard because (check one):

I am permanently blind or visually impaired as defined by IC 12-7-2-21 or 12-7-2-198. (This requires the completion of SECTION 3B of the

Practitioner's Certification below by an optometrist or ophthalmologist. A separate attachment is not acceptable.)

the above-named corporation, partnership or unincorporated association operates programs (including the provision of transportation), or facilities

for persons with disabilities and is empowered by the State of Indiana or its political subdivision to do so.

of a government entity / government contract. Beginning date (month, day, year)

Ending date (month, day, year)

I affirm under the penalties of perjury that the foregoing representations are true (parent or legal guardian must sign for persons under the age of sixteen).

Date (month, day, year)

Signature

NOTE: A person who knowingly and falsely represents himself as having the qualification to obtain a disability placard commits a Class C misdemeanor pursuant to IC 9-14-5-9.

SECTION 3 - PRACTITIONER'S CERTIFICATION

Please complete Section 3A or 3B and sign in Section 3C.

Applicant is responsible for any costs associated with completion of certification.

SECTION 3A - PHYSICIAN'S AND CHIROPRACTOR'S CERTIFICATION

A. I certify that __________________________________ is severely restricted in mobility due to a pulmonary or cardiovascular disability, arthritic condition,

orthopedic condition or neurological impairment. This severe restriction in mobility is (check one)

permanent

temporary and is expected to end

on__________________ 20 _____ . (NOTE: The expected date must be filled in for temporary disabilities.)

B. I am (check one and sign Section 3C):

An advanced practice nurse licensed under IC 25-23.

A physician having an unlimited license

A chiropractor licensed under IC 25-10-1.

to practice medicine in Indiana.

A podiatrist licensed under IC 25-29-1.

A physician who is a commissioned medical

officer of the armed forces of the United States