Form Ps-18 - Application For Disability Plates/placard printable pdf download

MAINE BUREAU OF MOTOR VEHICLES

BMV Entered

APPLICATION FOR DISABILITY PLATES/PLACARD

BMV Use Only

New Application

Re-Application

Replacement

Additional Plates/Placards

__________________

Placard#

Disability Placard(s)

Number of Placards Requested __________

_______________________

Disability Plates

Current Plate Number: (_____)_________________

_______________________

(Please provide a copy of your current registration only if you are applying for disability plates.)

_______________________

Applicant’s Name:____________________________________ Registrant’s Name: ____________________________________

_______________________

_______________________________

________________________________

Address:

___________________

Plate #

___________________________

_______ ___________________________

_______

ZIP

________________

Issue Date:

:_____________________________

Date of Birth

Date of Birth: ________________________________________

________________

Exp. Date:

: (_____)__________________

Daytime Telephone Number

________________

Returned#:

________________

Replaced#:

Please make the expiration coincide with my license/ID’s expiration _______________

________________

Issued by:

License/ID # (7 digits)

APPLICANT’S STATEMENT OF UNDERSTANDING

I understand that I may park in a disability parking space when the vehicle is occupied by the disabled person and the vehicle is properly

displaying disability plates or a placard. I understand disability applications are valid for up to four (4) years and that I must reapply before

the expiration date.

I understand the Secretary of State may restrict or suspend my driver’s license based on the information provided by my physician,

physician’s assistant, or nurse practitioner or registered nurse. With this understanding, I hereby give permission for my medical provider

to release my medical history to the Secretary of State, Bureau of Motor Vehicles to determine my eligibility for a driver’s license.

I may take this completed application to my nearest Motor Vehicle Branch Office or mail it to:

Disability Clerk, Bureau of Motor Vehicles, 29 State House Station, Augusta, ME 04333-0029.

If you have any questions, please call (207) 624-9000 ext 52149 Fax (207) 624-9204

***** Altered forms will be returned to the applicant*****

Applicant’s Signature _________________________________________________________________ Date: _________________

MEDICAL PROVIDER’S STATEMENT

Permanent (4 year maximum) – Please refer to “Certificate of Examination” on the reverse side of this form.

Temporary for a period of _______ months (6 months maximum)

Please check one of the following conditions:

Cannot walk two hundred feet without stopping to rest.

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

wheelchair, or other assistive device.

Is restricted by lung disease to such an extent that the person’s 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 mm/hg

of room air at rest.

Uses portable oxygen.

Has a cardiac condition to the extent that the person’s functional limitations are classified in severity as Class III or

Class IV according to the standards set by the American Heart Association.

Is severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition.

Is recovering from childbirth: TEMPORARY PLACARD ONLY - check appropriate box below

Cesarean delivery – valid for 1 week following receipt of application;

For the birth of a preterm infant, valid for ______ (specify length of time, not to exceed 6 months)

Name of Physician, Physician’s Assistant, Nurse Practitioner or Registered Nurse

Title: _________________________________________

(please type)________________________________________________

Signature:

Date: _________________________________________

Address:

Telephone #: ___________________________________

_____________________________________________________ License Number: ________________________________

PS-18 Rev. 9/09

Form Ps-18 - Application For Disability Plates/placard

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