Application For Disability Parking Certificate
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3MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Print Form
DRIVER AND VEHICLE SERVICES
FOR CENTRAL OFFICE USE ONLY
445 Minnesota Street, St. Paul, MN 55101-5164
Phone: (651) 297-3377 Web: dvs.dps.mn.gov
APPLI CAT IO N FO R DI S ABI LI TY PA RK IN G CE RT IF IC AT E
DISABLED INDIVIDUAL SECTION
To be completed by or for the person with a disability
Full Name (Please Print) Last, First and Middle
Date of Birth
Street Address
Is applicant a Minnesota Licensed driver?
Yes
No
No
Yes
Does applicant have a Minnesota Identification Card?
City
State
Zip
-
-
-
-
License/ID Number
Yes
No
Has applicant ever had a Minnesota Disability Parking Certificate
Minn. disability license plates?
Yes
No
List certificate and/or plate #:
Check here if this application is for two parking certificates*
Check here if this application is for a second parking certificate
*Two certificates are not an option if applicant has disability license plates
Limit 2 per applicant without disability license plates.
If applying for replacement, check reason:
Lost
Stolen
Damaged
Other;
Please Explain:
I hereby certify the above information is complete and accurate to the best of my knowledge. I also give permission to the Health Professional to
supply the information requested.
Date:
Signature
HEALTH PROFESSIONAL MEDICAL STATEMENT SECTION
Certificate Type:
IMPORTANT!
g
Certificate Expiration Date
Temporary 1 to 6 Months
Fee: $5 ea.
Must Specify
If no date is indicated
g
Short Term 7 to 12 Months
Fee: $5 ea.
the certificate will be issued for the
Must Specify
/
minimum duration of certificate type
Long-Term 13 to 71 Months
No Fee
g
Must Specify
Month
Year
No Fee
6-year Certificate For permanent disabilities
Deputy Stamp
The applicant must meet one or more of the definition(s) of a "physically disabled person" described below:
.
.
Check which definition(s) the applicant meets
.
Listing "symptoms" such as Back Pain, Leg Pain, etc. will require further explanation, causing delays in issuance
Incomplete/missing information will cause significant delays in issuance
The Applicant
1.
Has a cardiac condition to the extent that the applicant's functional limitations are classified in severity as Class III or
Class IV according to the standards set by the American Heart Association.
2.
Uses portable oxygen
NO FEE
FEE PAID
3.
Has an arterial oxygen tension (PAO ) of less than 60 mm/Hg on room air at rest.
2
Is restricted by a respiratory disease to such an extent that the applicant's forced (respiratory) expiratory volume for one second, when measured by
4.
spirometry, is less than one liter.
5.
Has lost an arm or leg and does not have or cannot use an artificial limb.
Disability Definitions 6-9 below must state the specific diagnosis of the condition causing disability.
6.
Due to disability, uses a wheelchair or cannot walk without the aid of:
Another Person; A Walker; A Cane; Crutches; Braces; A Prosthetic Device; or other Assistive Device _______________________________;
(Specify Diagnosis of condition causing Disability):
7.
Has a disability that would be aggravated by walking 200 feet under normal environmental conditions to an extent that would be life-threatening
This condition is:
8.
Due to disability cannot walk 200 feet without stopping to rest
This condition is:
9.
Cannot walk without a significant risk of falling
This condition is:
Is the applicant qualified, in all medical respects, to exercise reasonable and ordinary control over a motor vehicle?
Yes
Yes, with adaptive equipment
No, please specify:
Failure to answer this question will result in a request for a medical report.
I certify, by my signature as a licensed Physician, Physician's Assistant, Advanced Practice Registered Nurse or Chiropractor that, in my
(Patient's Name) meets the definition of physically disabled person and is entitled to
professional opinion
a disability parking certificate. I would be guilty of a misdemeanor and subject to a fine of $500 for fraudulently certifying the applicant.
Signature & Title
Date
Print Name
Telephone Number
Street Address, City, State and Zip Code
- over -
PS2005-31 (02/12)
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