Form 2769 - Application For Disabled Person Placard
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MISSOURI DEPARTMENT OF REVENUE
FORM
MOTOR VEHICLE BUREAU
2769
PO BOX 598, JEFFERSON CITY MO 65105-0598
(573) 526-3669
APPLICATION FOR DISABLED PERSON PLACARD
(REV. 06-2010)
SEE CONDITIONS AND RESTRICTIONS ON REVERSE
TEMPORARY PLACARD
PERMANENT PLACARD (NO FEE)
RECORD
CHANGE
NEW-$2
RENEWAL-$2
REPLACEMENT-$4
NEW
RENEWAL
REPLACEMENT
ONLY
NAME
ADDRESS
DO YOU CURRENTLY HAVE DISABLED LICENSE PLATE(S)?
YES
NO
CHANGE
CHANGE
HOW MANY DISABLED PLACARDS DO YOU CURRENTLY HAVE? ________
STATE REASON ADDITIONAL DISABLED PLACARD IS NEEDED IF REQUESTING MORE THAN ONE PLACARD:
LEGAL NAME OF DISABLED PERSON (LAST, FIRST, MIDDLE) OR BUSINESS
DATE OF BIRTH
GENDER
(PLEASE PRINT)
__ __ / __ __ / __ __ __ __
STREET, RFD, OR PO BOX NUMBER
DLN OR FEIN
CITY
STATE
ZIP CODE
__ __ __ __ __
MAIL TO: (IF DIFFERENT THAN ABOVE)
NAME
TELEPHONE NUMBER
(__ __ __) __ __ __ - __ __ __ __
STREET, RFD, OR PO BOX NUMBER
CITY
STATE
ZIP CODE
__ __ __ __ __
CHECK ALL BOXES THAT APPLY:
I hereby certify that I am
A disabled person
The parent or guardian of a disabled person
A representative of an agency that transports disabled persons
75 years old or older and am not required to submit a physician’s statement at time of renewal
ANY FALSE STATEMENT IS A VIOLATION OF THE LAW AND MAY BE PUNISHED BY FINE,
IMPRISONMENT, OR BOTH. FRAUDULENT APPLICATION, RENEWAL, ISSUANCE, PROCUREMENT, OR
USE OF DISABLED PERSON LICENSE PLATES OR WINDSHIELD PLACARDS IS A MISDEMEANOR.
SIGNATURE OF APPLICANT REQUIRED
TELEPHONE NUMBER
(__ __ __) __ __ __ - __ __ __ __
IF REPLACEMENT PLACARD IS REQUIRED, COMPLETE THE FOLLOWING:
REASON REQUIRED
NEVER RECEIVED
LOST
STOLEN
MUTILATED
DESTROYED
(REPLACE AT NO FEE)
NOTARY INFORMATION —
NOTARY IS REQUIRED FOR REPLACEMENTS ONLY
STATE
SUBSCRIBED AND SWORN BEFORE ME THIS
DAY OF
NOTARY PUBLIC NAME (TYPED OR PRINTED)
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC EMBOSSER SEAL OR STAMP
COUNTY (OR CITY OF ST. LOUIS)
USE RUBBER STAMP IN CLEAR AREA BELOW
FOR OFFICE USE ONLY
PREVIOUS PLACARD NO.
EXPIRATION DATE
FEE
SIGNATURE
FEE
__ __ / __ __ / __ __ __ __
GOOD CAUSE FOR ADD’L PLACARD
NEW PLACARD NO.
EXPIRATION DATE
NOTARY (REPLACEMENT ONLY)
__ __ / __ __ / __ __ __ __
DATE OF PHYSICIAN’S STATEMENT
APPROVED BY
__ __ / __ __ / __ __ __ __
MO 860-1674 (06-2010)
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