Fillable Disabled Parking Plates Or Placard Application printable pdf download

DISABLED PARKING PLATES OR PLACARD APPLICATION

MED 10 ( Rev. 07/02)

FOR PASSENGER CARS PICKUP OR PANEL TRUCKS OR MOTORCYCLES

SEE BACK FOR ELIGIBILITY REQUIREMENTS

LOG

NUMBER

PLEASE PRINT IN INK OR TYPE

ALL APPLICANTS COMPLETE THIS SECTION

APPLICANT INFORMATION

Placard Fee $5.00

Disabled Parking Plates

Disabled Parking Placard

Temporary

Application for:

Permanent-Original

Make check or money

(metal license plates)

(hangs from rearview mirror)

Check box(es) that apply:

Permanent-Renewal (No

order made payable

Physician’s Certification required)

to DMV.

Full Legal Name

Social Security/Driver’s License Number

last

first

middle

Residence/Home Address

Check here if this is a new address.

If you change either your residence/home address or mailing address to a non-Virginia address, your driver’s license and/or photo

identification (ID) card may be canceled.

City

State

Zip Code

City or County of Residence

Mailing Address

City

State

Zip Code

Daytime Telephone Number

(

)

Date of Birth

Sex

Hair Color

Eye Color

Height

Weight

NOTICE: Knowingly making a false claim or statement on this application is punishable as a class 2 misdemeanor. Misuse, counterfeiting, or alteration

of disabled placards may result in fines up to $1000 and up to six months in jail and or revocation of disabled parking privileges.

Permanent Disability: I hereby knowingly certify under penalty of fraud and/or perjury that I have a permanent disability that limits or impairs my ability

to walk; and that all the information I have provided is true.

Signature:

Date:

Temporary Disability: I hereby knowingly certify under penalty of fraud and/or perjury that I have a temporary disability that limits or impairs my ability

to walk; and that all the information I have provided is true.

Signature:

Date:

VEHICLE INFORMATION

PLATE APPLICANTS COMPLETE THIS SECTION

Check here if this vehicle is specially

Vehicle Identification Number

Title Number

equipped and used for transporting groups of

physically disabled persons.

PHYSICIAN COMPLETE THIS SECTION (NOT REQUIRED FOR RENEWAL)

PHYSICIAN CERTIFICATION

I certify and affirm that the above described applicant is my patient whose ability to walk, in my professional opinion, is:

PERMANENTLY limited or impaired. A “permanent disability” as it relates to disabled parking privileges shall mean: a physical condition that limits

or impairs movement from one place to another or the ability to walk as defined in Va. Code §46.2-1240, and that has reached the maximum level

of improvement and is not expected to change even with additional treatment.

TEMPORARILY limited or impaired beginning in the month of ____________ and ending in the month of ____________ (not to exceed 6 months).

The reason this patient’s ability to walk is limited or impaired is checked below:

Cannot walk 200 feet without stopping to rest.

Uses portable oxygen.

Cannot walk without the use of or assistance from any of the following: another person, brace, cane, crutch, prosthetic device, wheelchair, or

other assistive device.

Has a cardiac condition to the exent that functional limitations are classified in severity as Class III or Class IV according to standards set by the

American Heart Association.

Is restricted by lung disease to such an extent that forced (respiratory) expiratory volume for one second, when measured by spirometry, is less

than one liter, or the arterial oxygen tension is less than sixty millimeters of mercury on room air at rest.

OTHER DEBILITATING CONDITION that limits or impairs the ability to walk. PHYSICIAN MUST SPECIFY CONDITION

THE PHYSICIAN’S MEDICAL LICENSE INFORMATION IS REQUIRED TO PROCESS THIS APPLICATION.

Physician’s Name (Please print or type.)

Date

Medical License Number

Medical License Expiration Date

State Issuing Medical License

Office Telephone Number

(