DISABLED PARKING PLACARD
MED 011 (09/25/2008)
For Passenger Vehicles and Pickup/Panel Trucks Only
Use this form to apply for institutional/organizational disabled parking placards.
Complete the appropriate information below. Return the form to the Department of Motor Vehicles, Data
Integrity, Post Office Box 85815, Richmond, Virginia 23285-5815.
The institution or organization requesting the placard must be a hospital, hospice, nursing home, non-profit entity or
organization that does not charge for its services. No medical certification is needed. There is no fee for Institutional/
Organizational Disabled Parking Placard(s). The placard(s) will be mailed within appoximately 15 days.
NUMBER OF PLACARD(S) REQUESTED
DMV USE ONLY
FEDERAL IDENTIFICATION NUMBER (FIN)
CURRENT MAILING ADDRESS
Check here if this is a new address. (DMV must have your current mailing address.)
As an authorized representative of the above institution/organization, I understand that it is unlawful to knowingly make a false
statement on this application and that such a violation will be punished as a Class 2 misdemeanor. I certify that I am aware of the
penalties for violating the disabled parking placard laws, and I understand that misusing or allowing the misuse of the placard(s)
issued to this institution/organization can result in revocation of the placard(s). I also certify that the disabled placard(s) issued to the
above institution/organization will be used only when transporting disabled persons.
AUTHORIZED REPRESENTATIVE NAME (print)
AUTHORIZED REPRESENTATIVE SIGNATURE
DMV USE ONLY
ISSUE DATE (mm/dd/yyyy)
ISSUED BY (print DMV representative name)