Virginia

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

CITY

STATE

ZIP CODE

CITY OR COUNTY OF RESIDENCE

DAYTIME TELEPHONE NUMBER OR CELL PHONE NUMBER

CURRENT RESIDENCE ADDRESS

CITY

STATE

ZIP CODE

BIRTH DATE (mm/dd/yyyy)

HAIR COLOR

EYE COLOR

HEIGHT

WEIGHT

APPLICATION TYPE (select one)

ORIGINAL APPLICATION:

DISABLED PARKING PLACARD No fee required (includes ID Card) DISABLED PARKING LICENSE PLATE

RENEW PERMANENT DISABLED PARKING PLACARD

LOST or STOLEN plate?

APPLICATION FOR REPLACEMENT/REISSUE:

DISABLED PARKING PLACARD No fee required (includes ID Card)

DISABLED PLACARD ID CARD ONLY No fee required

DISABLED LICENSE PLATE ($10.00 fee)

REASON FOR REPLACEMENT/REISSUE

Lost Destroyed/Mutilated Stolen Never Received

DISABLED PARKING LICENSE PLATES (HP) (check one, if applicable)

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/parent/legal guardian)

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):

Temporary Permanent

disability that limits or impairs 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/PARENT/LEGAL GUARDIAN SIGNATURE

DATE (mm/dd/yyyy)

DMV USE ONLY

TEMPORARY PLACARD (up to 12 months)

ORIGINAL (Medical professional certification required.) REPLACEMENT/REISSUE

HP PLATES

ORIGINAL PLATES REPLACEMENT/REISSUE

15-DAY PLACARD RECEIPT NUMBER

The front of this form must be completed before the medical professional signs the certification.

NOTE: (This page does not have to be completed to renew permanent placards.)

Temporarily limited or impaired

beginning date (mm/dd/yyyy)

and ending date (mm/dd/yyyy) (not to exceed 12 months).

Permanently limited or impaired. A permanent disability as it relates to disabled parking privileges shall mean: a condition that limits or impairs movement from one place to another or the ability to walk as defined in Virginia Code §46.2-1240, and that has reached the maximum level of improvement and is not expected to change even with additional treatment.

LICENSED PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER MEDICAL CERTIFICATION

Other condition that limits or impairs the ability to walk, or creates a safety concern while walking because of impaired judgement or other physical, developmental, or mental limitation (Specific condition description must be specified below).

LICENSED CHIROPRACTOR OR PODIATRIST MEDICAL CERTIFICATION

Reason this patient's ability to walk is limited or impaired. (check below)

Cannot walk 200 feet without stopping to rest. Is severely limited in ability to walk due to an arthritic, neurological or orthopedic condition. Cannot walk without the use of or assistance from any of the following: another person, brace, cane, crutch, prosthetic device, wheelchair, or other assistive device.

Other condition that limits or impairs the ability to walk (Specific condition description must be specified below).

LICENSED CHIROPRACTOR OR PODIATRIST MEDICAL CERTIFICATION
I certify and affirm that the described applicant is my patient, whose ability to walk, based on my examination, is limited or impaired or creates a safety concern while walking as described above.
I further certify and affirm that to the best of my knowledge and belief, all information I have 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.

Physician

Physician Assistant

Nurse Practitioner

Chiropractor

Podiatrist

MEDICAL PROFESSIONAL NAME (print)

OFFICE TELEPHONE NUMBER

OFFICE FAX NUMBER

LICENSE TYPE

LICENSE NUMBER

LICENSE EXPIRATION DATE (required)

STATE ISSUING LICENSE (required)

MEDICAL PROFESSIONAL SIGNATURE