State Form 42070 - Application For Disability Plate Or Parking Placard Page 2
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1
2APPLICATION FOR DISABILITY PLATE OR PARKING PLACARD
State Form 42070 (R13 / 11-13)
Approved by State Board of Accounts, 2013
INDIANA BUREAU OF MOTOR VEHICLES
SECTION 4A - PRACTITIONER'S CERTIFICATION OF SEVERELY LIMITED MOBILITY
Name of Applicant (first, middle, last)
Date of Birth (mm/dd/yyyy)
I certify that the applicant meets the qualifications as outlined by Indiana law to receive a disability placard and/or license plate.
This disability is:
Permanent
Temporary and is expected to end on:
/
/
(mm/dd/yyyy)
I am:
A physician with a valid and unrestricted license to practice medicine in Indiana.
A physician with a valid and unrestricted license to practice medicine from a state other than Indiana. (Placards only)
A physician who is a commissioned medical officer of the United States Armed Forces or the United States Public Health
Service. (Placards only)
An advanced practice nurse with a valid and unrestricted license under Indiana Code 25-23. (Placards only)
A chiropractor with a valid and unrestricted license under Indiana Code 25-10-1. (Placards only)
A podiatrist with a valid and unrestricted license under Indiana Code 25-29-1. (Placards only)
A physician who is a medical officer of the United States Department of Veterans Affairs. (Placards only)
Signature
Printed Name
Date Signed (mm/dd/yyyy)
Telephone Number
License Number
(
)
Address (number and street)
City
State
ZIP Code
SECTION 4B - PRACTITIONER'S CERTIFICATION OF BLINDNESS OR VISUAL IMPAIRMENT
Name of Applicant (first, middle, last)
Date of Birth (mm/dd/yyyy)
I certify that the applicant is blind or visually impaired as defined by Indiana law and may receive a disability placard and/or
license plate. This condition is:
Permanent
Temporary and is expected to end on:
/
/
(mm/dd/yyyy)
I am:
An ophthalmologist with a valid and unrestricted license to practice in Indiana
An optometrist with a valid and unrestricted license to practice in Indiana
Signature
Printed Name
Date Signed (mm/dd/yyyy)
Telephone Number
License Number
(
)
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