Disability-Hearing Impaired Plate/placard Application
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1
2DISABILITY – HEARING
Mail Drop 801Z
IMPAIRED PLATE/PLACARD
Special Plates Unit
Clear
Motor Vehicle Division
APPLICATION
PO Box 2100
Application Type: New Plate New Placard
Phoenix AZ 85001-2100
azdot.gov
96-0104 R07/14
For renewals, use form # 40-0112, available online.
Applicant Name
Phone
Date of Birth
Driver License Number
(person with a disability or hearing impaired or organization)
(
)
Applicant Mailing Address
City
State
Zip
Plate Applicants: Vehicle information below is for plate applicants only (vehicle must be owned or leased by the person with a disability or hearing impaired)
Vehicle Identification Number
Year
Make
Current Plate Number
Physical Disability — International Symbol of Access, for parking in specially marked spaces
Medical Certification must be completed by an authorized physician (doctor of medicine, osteopathy, podiatry or chiropractic, licensed to practice
medicine in the United States), a registered nurse practitioner or by a hospital administrator. Applicant must have one or more of the following
conditions.
— Visual impairment in and of itself does not qualify a person for a plate or placard. —
• Unable to walk 200 feet without stopping to rest
• Unable to walk without help from another person or a brace, cane, crutch, wheelchair or other prosthetic or assistive device
• Lung disease with forced respiratory, expiratory volume for one second, if measured by spirometry, is less than one liter, or the arterial oxygen
tension is less than 60 mm/hg on room air at rest
• Uses portable oxygen
• Cardiac condition with Class 3 or 4 functional limitations as by American Heart Association standards
• Severely limited in ability to walk due to an arthritic, neurological or orthopedic condition
Hearing Impaired — To alert law enforcement and others to the driver’s condition (not for special parking privileges)
Medical Certification must be completed by a person licensed to practice medicine in the United States or an audiologist certified by the American
Speech, Language and Hearing Association. Applicant must be unable to hear or understand normal speech, with or without a hearing aid, in optimal
conditions.
Medical Certification
Health Professional Name *
Phone
Fax
(
)
(
)
Hospital Name (if signed by Administrator)
Mailing Address
City
State
Zip
I certify that the applicant has one or more of the conditions listed above and for that reason is:
Permanent Physical Disability
Temporary Physical Disability (must be recertified after 6 months)
Hearing Impaired
Health Professional Signature (stamp not accepted) *
Medical License or Certification Number
Date
* Must be authorized physician (see above), registered nurse practitioner, audiologist or hospital administrator. Stamp Not Accepted
Individual Applicants
I certify (or declare) that the foregoing is true and correct. I have read the front and back of this form and I fully understand and take
responsibility for the use of the Disability Placard(s) or Plates that are issued to me.
The Medical Certification above was not completed because:
Plate/Placard Number
State
One is already on file for the following plate/placard
A
uthorized from another state (indicate plate/placard number and state)
Applicant Signature
Date
(person with a disability or hearing impaired)
Organization Applicants
I certify (or declare) that the foregoing is true and correct. I have read the front and back of this form and I fully understand and take
responsibility for the use of the Disability Placard(s) or Plates that are issued to this organization.
The vehicle indicated above is primarily used to transport physically disabled persons who have one or more of the conditions listed
above.
The Nonprofit Organization/Applicant indicated above provides assistance to senior citizens.
Authorized Officer Name
Officer Signature
Date
Plate #
Placard #
MVD
Office
Issue
MVD Use
Issued
Issued
Agent
Date
Placard #
Placard #
Placard #
Non-Profit Organization
Issued
Issued
Issued
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