Form Sfn 2886 - Application For Mobility-Impaired Parking Permit Page 2
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2SFN 2886 (2-2017)
Page 2 of 2
TO BE COMPLETED BY QUALIFIED MEDICAL PROVIDER
PLEASE CHECK ONE
NON-REVERSIBLE CONDITION
The permit will expire 12-31-2018.
The applicant will not have to contact a qualified medical provider to renew the permit.
REVERSIBLE CONDITION
The permit will expire 12-31-2018.
To renew the permit, the applicant will need to have the qualified medical provider complete a new application.
TEMPORARY MOBILITY IMPAIRMENT
The permit is good for 3 months.
I verify the following applicant is mobility impaired as defined in 39-01-15 (NDCC).
Applicant's Name (Type or Print)
Applicant is restricted by cardiac, pulmonary or vascular
Applicant uses portable oxygen.
disease from walking two hundred feet without rest.
Applicant has a forced expiratory volume of less than one liter
Applicant has an orthopedic, neurologic, or other medical
for one second or an arterial oxygen tension of less than 60
condition that makes it impossible to walk two hundred feet
millimeters of mercury on room air while at rest and is
without assistance and rest.
classified III or IV by standards for cardiac disease set by the
American Heart Association.
Name of Clinic
Telephone Number
Address of Clinic
City
State
ZIP Code
Printed Medical Provider's Name
Medical Provider's Signature
Date
NOTE: A Qualified Medical Provider who provides a false statement that a person is mobility impaired for the purpose of that person
obtaining a certificate under the subsection is guilty of an infraction for which a minimum fine of one hundred dollars must be imposed.
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