Form Med 10 - Disabled Parking Placard Or License Plates Application
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2MED 10 (10/25/2017)
DISABLED PARKING PLACARD
OR LICENSE PLATES
APPLICATION
Purpose:
Persons with disabilities use this form to apply for a disabled parking placard or disabled parking license plates.
Instructions: For a parking placard OR replacement placard ID card, submit this form with applicable fees. Placard or replacement ID
card will be mailed to you within approximately 15 days. Only one placard may be issued to a customer.
For disabled parking license plates, submit this form, a completed License Plate Application (VSA 10) and applicable fees.
For placard and/or license plates, submit forms and fees to any Customer Service Center, DMV Select or mail to DMV,
Data Integrity, P.O. Box 85815, Richmond, VA 23285-5815.
APPLICANT INFORMATION (person with disability)
FULL LEGAL NAME (last) (first) (middle) (suffix)
DMV ASSIGNED NUMBER OR SOCIAL SECURITY NUMBER
NOTE: If you enter a residence or mailing address that is other than what is currently on DMV's system, complete an "Address Change Request" (ISD 01).
CURRENT RESIDENCE ADDRESS (SEE NOTE ABOVE)
CITY
STATE
ZIP CODE
CITY OR COUNTY OF RESIDENCE
DAYTIME TELEPHONE NUMBER OR CELL PHONE NUMBER
(
)
MAILING ADDRESS (if different from above) (SEE NOTE ABOVE)
CITY
STATE
ZIP CODE
BIRTH DATE (mm/dd/yyyy)
GENDER
HAIR COLOR
EYE COLOR
HEIGHT
WEIGHT
IN
MALE
FEMALE
FT
LBS
APPLICATION TYPE
ORIGINAL APPLICATION:
(check applicable)
*
Only permanently disabled persons or institutions that transport
DISABLED PARKING PLACARD
DISABLED PARKING LICENSE PLATE
*
individuals with disabilities may obtain disabled license plates.
$5.00 fee (includes ID Card)
(complete form VSA 10)
APPLICATION FOR REPLACEMENT:
REASON FOR REPLACEMENT - original was:
(check applicable)
Lost
Stolen
DISABLED PARKING PLACARD
DISABLED PLACARD ID CARD ONLY
DISABLED LICENSE PLATE
$5.00 fee (includes ID Card)
$2.00 fee
$10.00 fee
Destroyed/Mutilated
Never Received
DISABLED PARKING LICENSE PLATES (HP) (check one)
The vehicle on which HP plates will be used is specifically equipped and used for transporting groups of physically disabled persons.
I am the vehicle owner and the parent/legal guardian of a disabled dependent(s). List the name of each disabled person below.
APPLICANT CERTIFICATION (person with disability)
I understand that misuse, counterfeiting, or alteration of disabled placards may result in fines up to $1000.00 and up to 6 months in jail
and/or revocation of disabled parking privileges. I certify that I have a (check one):
disability that limits or impairs
Temporary
Permanent
my ability to walk or creates a safety concern while walking.
I also understand that the disabled parking placard or plates issued to me cannot be loaned to anyone, including family members or friends, to
benefit a person other than myself.
I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine,
and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of
perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
APPLICANT SIGNATURE
DATE (mm/dd/yyyy)
DMV USE ONLY
TEMPORARY PLACARD (up to 6 months)
15-DAY PLACARD RECEIPT NUMBER
Placard
Placard ID
License Plate
Replacement
ORIGINAL
REISSUE
Lost
Stolen
Destroyed/Mutilated
PLACARD EXPIRATION DATE (mm/dd/yyyy)
PERMANENT PLACARD (5 years)
ORIGINAL
REISSUE
EMPLOYEE STAMP
(Medical professional certification required.)
Replacement
RENEWAL
Placard
Placard ID
License Plate
(No medical professional certification required.)
Lost
Stolen
Destroyed/Mutilated
HP PLATES
ORIGINAL PLATES
DUPLICATE PLATES
REISSUE PLATES
submit completed
Lost
Unreadable (letters/numbers unclear)
form VSA 10
Destroyed
Plates never received
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