Institutional/organizational Disabled Parking Placard Application
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1INSTITUTIONAL/ORGANIZATIONAL
DISABLED PARKING PLACARD
MED 011 (09/25/2008)
APPLICATION
For Passenger Vehicles and Pickup/Panel Trucks Only
Purpose:
Use this form to apply for institutional/organizational disabled parking placards.
Instructions:
Complete the appropriate information below. Return the form to the Department of Motor Vehicles, Data
Integrity, Post Office Box 85815, Richmond, Virginia 23285-5815.
PLACARD INFORMATON
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
LOG NUMBER
DMV USE ONLY
APPLICANT INFORMATION
INSTITUTION/ORGANIZATION NAME
FEDERAL IDENTIFICATION NUMBER (FIN)
CURRENT MAILING ADDRESS
TELEPHONE NUMBER
Check here if this is a new address. (DMV must have your current mailing address.)
(
)
CITY
STATE
ZIP CODE
CERTIFICATION
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
DATE (mm/dd/yyyy)
DMV USE ONLY
PLACARD NUMBER
ISSUE DATE (mm/dd/yyyy)
ISSUED BY (print DMV representative name)
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