Form Mv-664.1fc - Application For A Parking Permit Or License Plates, For People With Severe Disabilities (Haitian Creole) Page 3
Download a blank fillable Form Mv-664.1fc - Application For A Parking Permit Or License Plates, For People With Severe Disabilities (Haitian Creole) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Mv-664.1fc - Application For A Parking Permit Or License Plates, For People With Severe Disabilities (Haitian Creole) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4DETAchE
nan
APLIKASYON POU YON PÈMI PAKIN OSWA PLAK
Tanpri
KI GEN TI TWOU YO
kote
IMATRIKILASYON, POU MOUN KI GEN ANDIKAP GRAV
É
epi konsève paj 1 ak 2
pou enfòmasyon ou.
Tanpri li paj 1 ak 2 blòk dokiman sa a anvan ou ranpli aplikasyon sa a. Si ou aplike pou yon pèmi pakin, pote aplikasyon an ba ajan ki bay
pèmi an (minisipalite lokal) nan vil, ti vil oswa vilaj kote w ap viv la;
pa voye aplikasyon ou nan Depatman Veyikil-a-Motè paske DMV pa
bay pèmi pakin.
Pati 1 ENFÒMASYON SOU MOUN KI GEN ANDIKAP
— (Tanpri ekri an lèt detache epi siyen non ou toupre flèch la.)
Non Fanmi
Prenon
Dezyèm Prenon
Nimewo Telefòn
(
)
Adrès: Nimewo Kay ak Ri
Nimewo
Vil
Eta
Kòd Postal
Apatman
o
o
o
o
Dat Ou Fèt
Mwen vle:
Plak Imatrikilasyon (Aplike pou DMV.)
Yon Pèmi Pakin
Gason
Fanm
(Aplike nan biwo yon ajan lokal ki bay pèmi an.)
Èske ou gen plak imatrikilasyon pou moun ki andikape?
Rezidan Vil New York - Tache la a yon kopi lisans chofè machin ou an oswa kat idantite
pou moun ki pa kondwi ou an. Si ou te gen yon pèmi pou Eta New York, ekri nimewo an
o
o
Wi - Nimewo plak imatrikilasyon mwen se:___________
Non
la a:
Li nòt ki nan paj 4 la anvan ou siyen non ou
Si se yon paran oswa yon
(Dat la)
(Siyati Moun ki Andikape a oswa Siyati Paran oswa Responsab Legal) —
responsab legal ki siyen, tanpri ekri sa ou ye pou moun ki andikape a apre siyati ou.
Pati 2 SÈTIFIKA MEDIKAL
NÒT: Yon Doktè Medikal [Medical Doctor (MD)], yon Doktè Osteyopati [Doctor of Osteopathy (DO)], yon Asistan Doktè [Physician Assistant (PA)],
yon Enfimyè Pratisyen [Nurse Practitioner (NP)], yon Doktè Lamedsin Podyatrik [Doctor of Podiatric Medicine (DPM, pou andikap ki gen pou wè a
pye)] oswa yon Optometris [Optometrist (OD, pou moun ki avèg)] ka bay yon sètifika pou ANDIKAP PÈMANAN. Men se sèlman yon Doktè
Medikal oswa yon Doktè Osteyopati ki ka bay yon sètifika pou ANDIKAP POU YON TI TAN.
Koche kaz (yo) ki dekri andikap la, epi mete dyagnostik la:
o
ANDIKAP POU YON TI TAN: Yon moun ki gen yon andikap pou yon ti tan se nenpòt moun ki pa kapab deplase pou yon ti tan san èd yon
aparèy sipò. Kèk egzanp aparèy sipò se, men pa sèlman, yon atèl, yon badin, yon bekiy, yon aparèy pwotetik, yon lòt moun, yon chèz-woulant
oswa yon kad pou mache.
Nou bay pèmi pwovizwa yo pou sis (6) mwa oswa mwens kèlkeswa dat doktè prevwa pou refè.
ENPÒTAN:
______________________
_____________________________________________________
Dat ki Prevwa pou Refè:
Dyagnostik:
________________________________________________________________________________
Ki aparèy sipò ki nesesè?
o
ANDIKAP PÈMANAN: Yon moun ki gen “andikap pèmanan” se nenpòt moun ki gen youn oswa plis andikap PÈMANAN, andikap
oswa pwoblèm medikal ki endike anba la a, ki limite mobilite moun nan.
___________________________________________________ Tanpri
Dyagnostik:_
koche kaz pou pwoblèm medikal ki konsène ou:
o
o
o
o
I
tilizasyon oksijèn pòtatif
Avèg legalman
Limite oswa pa kapab itilize toulède janm yo
Pa kapab mache sou yon distans 200 pye san ou pa kanpe
o
o
Disfonksyon newo-miskilè ki limite mobilite a yon fason grav
Pwoblèm kadyak Klas III oswa IV (Kondisyon American Heart Association)
o
Limite yon fason grav nan mwayen pou mache akòz yon pwoblèm atrit, yon pwoblèm newolojik oswa yon pwoblèm òtopedik
o
Gen restriksyon akòz maladi poumon nan yon limit ki lakòz volim ekspiratwa (respiratwa) pa segonn, lè li mezire nan espiwometri, pi piti pase yon
lit, oswa presyon ateryèl nan oksijèn nan pi piti pase swasant (60) mm/hg lè chanm pandan ou nan repo
o
Gen yon andikap yon pwoblèm fizik oswa mantal ki pa endike anwo a ki se yon degre andikap egal, epi ki lakòz moun nan gen difikilte iregilye pou
itilize sèvis transpò piblik epitou ki anpeche moun nan deplase san gwo difikilte.
EKSPLIKE ANBA LA A KIJAN ANDIKAP SA A LIMITE MOBILITE FONKSYONÈL OU.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Non MD/DO/DPM/NP/PA/OD
Nimewo Lisans Pwofesyonèl
Adrès MD/DO/DPM/NP/PA/OD
Nimewo Telefòn
(
)
Li nòt ki nan paj 4 la anvan ou siyen non ou
(Siyati MD/DO/DPM/NP/PA/OD)
(Dat la)
Part 3 FILE INFORMATION
(For Issuing Agent Use Only)
o
o
Blue
Red Parking Permit No. __________________ Date Issued:_______________ Date Expires:_____________________
o
o
First
Second
9-digit number from NYS Driver License/ID Card ______________________________
o
o
Denied
Revoked Reason:________________________________________________________________
_________________
(Date)
___________________________________________________________________________________
(Issuing Agent)
(Locality)
MV-664.1FC (2/17)
PAJ 3 / 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Mv-664.1ch - Application For A Parking Permit Or License Plates, For People With Severe Disabilities (chinese)
Legal
Form Mv-664.1i - Application For A Parking Permit Or License Plates, For People With Severe Disabilities (italian)
Legal
Form Mv-664.1r - Application For A Parking Permit Or License Plates, For People With Severe Disabilities (russian)
Legal
Form Mv-664.1k - Application For A Parking Permit Or License Plates, For People With Severe Disabilities (korean)
Legal
Form Mv-664.1s - Application For A Parking Permit Or License Plates, For People With Severe Disabilities (spanish)
Legal
Form-664.1 - Application For A Parking Permit Or License Plates For Persons With Severe Disabilities
Legal
Related Categories
Parent category: Legal