Application For Disabled Person'S Special Parking Permit - Division Of Motor Vehicle Licensing Department Of Vehicle Regulation Kentucky Transportation Cabinet

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   Kentucky Transportation Cabinet 
TC 96‐204
                         
    
Department of Vehicle Regulation
01/2016
 
Division of Motor Vehicle Licensing 
APPLICATION FOR DISABLED PERSON’S SPECIAL  
PARKING PERMIT
 
INSTRUCTIONS:  Complete this form and forward to your County Clerk. 
SECTION 1: APPLICANT INFORMATION 
(to be completed by applicant before submitting to a physician) 
nd
  Issuance  
  2
 Permit  
  Renewal  
  Replacement 
Name 
           
Phone 
           
 
(Individual or Organization)
 
Address 
           
           
                       
(Street or Post Office)
(City) 
State
Zip
Date of Birth
(
mm/dd/yy)
 
 
 
Check all that apply: 
 Placard or 
 License Plate 
 Applicant now holds disabled parking plate or placard license #  
           
 Applicant now holds disabled veteran license # 
           
           
(Signature of Applicant) 
(FED ID/SSN) 
 
 
Subscribed and attested before me this date  
My
Commission
expires
.
 
 
  
/
/
.
/
/
 
Attesting Official or Notary Signature & Title 
 
SECTION 2: LICENSED PHYSICIAN CERTIFICATION 
(not valid if Section 1 is incomplete) 
 
I certify that the applicant is a person with disabilities which limit or impair the ability to walk 200 feet without stopping; 
without the use of assistance device; without portable oxygen; due to arthritic, neurological, or orthopedic condition; 
because they are restricted by lung disease; or because they have a cardiac condition in compliance with KRS 186.042 
and KRS 189.456. 
CHECK ONE: 
 Permanent disability valid for (2) years 
 Temporary disability valid for (3) months 
 
 
 
(Signature of Licensed Physician, Chiropractor, or Advanced Practice Registered Nurse)
 
(Printed Name of Licensed Physician, Chiropractor, or Advanced  Practice Registered Nurse)
(License #)
FOR COUNTY CLERK’S USE ONLY 
I hereby attest that the applicant is obviously disabled in compliance with KRS 186.042 and KRS 189.456 and should be 
issued a special parking permit. 
 
Signature of Clerk 
 
County   
 
Previous Placard #   
Expires   
 
New Placard #  
 
Expires   
Replacement Reason 
 
 

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