Form Sfn 2886 - Application For Mobility-Impaired Parking Permit
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1
2APPLICATION FOR MOBILITY-IMPAIRED
MOTOR VEHICLE DIVISION
ND DEPT OF TRANSPORTATION
PARKING PERMIT
608 E BOULEVARD AVE
North Dakota Department of Transportation, Motor Vehicle
BISMARCK ND 58505-0780
Telephone (701) 328-2725
SFN 2886 (2-2017)
Website: https://dot.nd.gov
For Motor Vehicle Use Only
2018 Placard Number(s)
TO BE COMPLETED BY APPLICANT (please print)
Applicant's Legal Name
Telephone Number
Mailing Address
City
Zip Code
State
I reside in the following county
North Dakota Driver's License Number
I certify that I am mobility-impaired, which renders it difficult and burdensome for me to walk.
Applicant's Legal Signature
Date Signed
Please choose ONE of the following:
PERMANENT MOBILITY-IMPAIRED PARKING PERMIT
Number of Permits Requested
1.
Mobility-Impaired Parking Permits ONLY - No Fee Required
(Check One)
With this option, you must display regular license plates on your vehicles.
1
2
**Complete ONLY if you are requesting Mobility-Impaired Plates.
2.
Mobility-Impaired License Plates with ONE Parking Permit - $5 fee required for each vehicle listed below
Year and Make of Vehicle
License Number
Year and Make of Vehicle
License Number
3.
Duplicate Permanent Mobility-Impaired Parking Permits - $3 EACH
Choose reason for Duplicate:
Lost
Stolen
Mutilated
possession
List placard number you have in your
________________
TEMPORARY MOBILITY-IMPAIRED PARKING PERMIT
Number of Permits Requested
Issued to individuals who are temporarily mobility impaired. Permits are $3 each and
(Check One)
4.
are valid for increments of 3 months.
Duplicate temporary mobility-impaired permits - $3 each
1
2
List placard number you have in your possession ____________________
Permit(s) must be prominently displayed on the rearview mirror of the motor vehicle whenever the vehicle is occupying a space reserved for the
mobility impaired and is being used by a mobility-impaired individual or another individual for the purposes of transporting the mobility-impaired
individual. No part of the permit may be obscured. A fee of five dollars may be imposed for a violation of this subsection.
NDCC 39-01-15 sub 8. If a law enforcement officer finds that the certificate is being improperly used, the officer may report to the director any
violation and the director may in the director's discretion, remove the privilege. An individual who is not mobility impaired and who exercises
the privileges granted a mobility-impaired individual under subsection 1 is guilty of an infraction for which a fine of one hundred dollars must be
imposed.
REVERSE SIDE MUST BE COMPLETED AND SIGNED BY QUALIFIED MEDICAL PROVIDER
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