Disability Parking Placard Application
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1
2MICHIGAN DEPARTMENT OF STATE
Disability Parking Placard Application
Office Use Only:
Expiration
Clear Form
Date:
Directions:
Placard
Applicants please complete and sign Part 1. Your physician, chiropractor, optometrist, nurse practitioner, or
Number:
physician’s assistant must complete Part 2 and the certification on the bottom of this page. If you also qualify
for free parking, your physician, chiropractor, optometrist, nurse practitioner, or physician’s assistant must
also complete Part 3. Organizations applying for parking placards to provide transportation services for disabled persons complete Part 4.
Completed applications may be presented at any Secretary of State branch office or mailed to the address on the reverse side of this form.
(Application cannot be processed without signed release of information and physician’s certification.)
Part 1: Release of Information and Signature
I am applying for a disability parking placard as provided in Public Act 300 of 1949. I authorize the release of the medical information
described below to the Michigan Department of State. I certify the information is true and realize by making a false statement on this
application I am subject to the penalties described on the reverse side of this form.
(Please print)
Name (First, Middle, Last)
Date of Birth
Michigan Drivers License or ID Card #
Street Address
County
Disability Plate Number (if any)
City, State, Zip
Daytime Phone Number
Last Parking Permit Number
(
)
Date
Signature of Disabled Person
Are you a Michigan resident?
X
YES
NO
Signature of Representative (If presented by representative)
Representative’s Driver License Number
X
Part 2: Medical Eligibility Standards and Physician’s Determination
The Michigan Vehicle Code [MCL 257.19a] states that a disabled person be determined by a licensed physician, physician’s assistant, chiropractor,
nurse practitioner, or optometrist identifying one or more of the following characteristics which affect your patient’s ability to walk.
Circle all letters that apply
Right Eye:
Left Eye:
Both Eyes:
Visual field (in degrees):
a) Blindness. Corrected acuity level:
20/______
20/______
20/______
____________
b) An inability to walk more than 200 feet without having to stop and rest. Please provide the diagnosis for this ambulatory
disability:_______________________________________________________________________________________
c) Patient must use a wheelchair, walker, crutch, brace, or other ambulatory aid to walk.
Describe:_______________________________________________________________________________________
d) Patient has a lung disease from which the forced expiratory volume for one second, when measured by spirometry, is less than
one liter, or from which the arterial oxygen tension is less than 60mm/hg of room air at rest.
e) Patient has a cardiovascular condition which measures between 3 and 4 on the New York Heart Classification Scale, or which
renders the patient incapable of meeting a minimum standard for cardiovascular health established by the American Heart
Association and approved by the Michigan Department of Public Health.
f) Patient has an arthritic, neurological, or orthopedic condition that severely limits ability to walk.
Describe: _______________________________________________________________________________________
g) Patient has a persistent reliance upon an oxygen source other than ordinary air.
Physician’s Certification
A parking placard will be issued solely on the physician’s evaluation
Patient’s condition is:
Permanent
Temporary
If temporary, estimated duration: ______months
(maximum 6 months)
Physician’s Name
Medical Specialty
Office Telephone
Street Address
City, State, Zip
Office Fax
I certify the person listed above is eligible for a disability placard as provided in Public Act 300 of 1949. I also understand that
making a false statement to obtain a disability parking placard is a misdemeanor and may result in fines, imprisonment, or both.
Physician’s Signature
Medical License Number *
Date
X
(Physician / Chiropractor / Physician’s Assistant / Optometrist / Nurse Practitioner)
*
If the medical license was issued in a state other than Michigan, the physician must submit a copy of their medical license.
BFS-108 (04/16)
NOTE: If the individual listed above is also eligible for free parking, Part 3 on the reverse side of this application must also be completed.
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