Form 861 - Alasaka Application For Special Disability Parking Permit - Division Of Motor Vehicles

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STATE OF ALASKA
DIVISION OF MOTOR VEHICLES
APPLICATION FOR SPECIAL DISABILITY PARKING PERMIT
PART 1. TO BE COMPLETED BY APPLICANT
(APPLICANT MUST BE THE PERSON NAMED AS “PATIENT” IN PART 2.)
FULL LEGAL NAME OF APPLICANT (PRINTED)
MAILING ADDRESS
CITY / STATE / ZIP
ID OR DRIVER LICENSE NUMBER
STATE
DATE OF BIRTH
SEX
M
F
EMAIL
DAYTIME TELEPHONE NUMBER
(
)
PART 2. TO BE COMPLETED BY PHYSICIAN, PHYSICIAN ASSISTANT, NURSE PRACTITIONER OR PODIATRIST
NAME OF PATIENT:
___________________________________________________________________________
To obtain a disability parking permit, the patient must meet one of the following requirements. Please check any that apply.
1.
Cannot walk 200 feet without stopping to rest
2.
Cannot walk without using a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device
3.
Is restricted by lung disease
4.
Uses portable oxygen
5.
Has a cardiac condition classified as Class III or Class IV according to standards set by the American Heart Association
6.
Is severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition
THIS DISABILITY IS:
PERMANENT
(valid for five years and renewable upon reapplication) (must have valid Alaska ID or License)
TEMPORARY
(valid up to six months and renewable upon reapplication)
Starting Date (mo/yr) __________ Ending Date (mo/yr) __________
Does your patient have a commercial driver license (CDL)?
YES
NO
If YES, does your patient meet the physical requirements under 49 CFR 391.41 to retain their CDL?
YES
NO
I certify as a licensed Alaskan physician, physician assistant, nurse practitioner, or podiatrist that the patient shown as the
applicant in Part 1 meets the definition(s) above and is eligible for a special disability parking permit or license plates with parking
privileges.
AUTHORIZED SIGNATURE
TITLE (CIRCLE ONE)
DATE
Physician
PA
Podiatrist
Nurse Practitioner
/
/ 20
PRINTED NAME & OCCUPATIONAL LICENSE NUMBER
CITY & ZIP CODE
TELEPHONE NUMBER
(
)
PART 3. DMV USE ONLY
VISITOR/TOURIST
PERMANENT
TEMPORARY
ORGANIZATION
REPLACEMENT - PREVIOUS
PERMIT / PLATE #
NEW PERMIT OR PLATE #
BATCH
OFFICE
Date
AMVC
Date
Supervisor AMVC
alaska.gov/dmv
Form 861 (Rev. 11/2016)

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