West Virginia Department of Transportation

Division of Motor Vehicles

Parking Application for a Mobility Impaired Person

Mail to: Mobility Impaired Placards & Plates • PO Box 17030 • Charleston, WV 25317

Questions: 1-800-642-9066 • dmv.wv.gov
PART I • TO BE COMPLETED BY THE APPLICANT (You must follow the instructions provided on the back of this form.)

A.) Applicant Information • DO NOT FORGET TO ENTER YOUR SOCIAL SECURITY NUMBER IN THE LIGHT GRAY BOX ABOVE.

Name

Gender

Birthdate

Phone Number

Address

Mailing Address (if different)

B.) Plate and/or Placard Information • License plates can only be issued to an applicant whose name appears on the WV vehicle registration.

Request for a Mobility Impaired Plate
Is this request due to a

LOST or STOLEN plate?

Request for a Mobility Impaired Placard
Is this request due to a

LOST or STOLEN plate?

C.) Vehicle and Insurance Information • This section is only required to be completed if this request is for a license plate.

Make

Weight

Model Year

Title Number

Current License Plate # (include space)

Vehicle Identification Number (VIN/SERIAL NUMBER)

Policy No.

Insurance Company

NAIC Number

Insurance Agent

C.) Applicant's Certification

I certify that I am a person with a mobility impairment which limits or impairs my ability to walk and that all of the information above is accurate. I understand that any false statement may result in legal penalties pursuant to West Virginia Code §17C-13-6. A parent or legal guardian may sign for the applicant if the is unable to do so. Please note your relationship to the applicant.

SIGNATURE OF APPLICANT OR SIGNATURE OF LEGAL GUARDIAN AND RELATIONSHIP TO THE APPLICANT

DATE

INSTRUCTIONS: Parking Application for a Mobility Impaired Person

ALL APPLICANTS MUST B E WEST VIRGINIA RESIDENTS

The mobility impaired person MUST enter their Social Security Number in the light gray box on the upper right corner of
the page. DO NOT
The mobility impaired person completes Section 1 and signs the application
A licensed physician completes Section 2. (Licensed physician includes MD., DO., Chiropractor, Advanced Nurse Practitioner,
and Physician’s Assistant)
Applicants requesting a mobility impaired license plate must be listed on the registration of the vehicle listed in Sub-Section C.
The completed application can be processed at any DMV Regional Office or submitted by mail to the address listed below:

Division of Motor Vehicles Mobility Impaired Placards and Plates

PO Box 17030
Charleston, WV 25317

Placard Information

When parked in a mobility impaired parking space, display the placard by hanging it on the rearview mirror, or, in the absence of a mirror post, on the dashboard.
If a parking placard or special license plate has been lost, stolen, mutilated or destroyed, a replacement may be requested at any DMV Regional Oce or by mail to the DMV in Charleston. The cost of a replacement placard is $5.00 per. The customer must complete a new application but a doctor’s recertification is not required.
Permanent mobility impaired license plates expire each year or every other year. Renewal reminders will be mailed prior to expiration to the address you provided

Situations that Warrant Returning Placards & Plates

The person to whom the permit has been issued is deceased or has moved out of state.
The person has found or has in his/her possession a permit that was not issued to that person.
The permit was reported lost or stolen and is later found after a duplicate has been

**Special plates shall be surrendered to your local DMV Regional Office.

**A fine of up to $500.00 may be assessed for filing fraudulent applications for a mobility impaired parking permit. This fine also applies to the misuse of a parking space reserved for persons with a walking mobility impairment.

Important Information

It is unlawful to loan this placard to any person for any reason, regardless of whether that person is mobility impaired. The mobility impaired person does not have to own or drive the vehicle to use the placard.

**Placard should be hung from the rearview mirror when parked but should be removed from the mirror when driving.
**Local governments designate parking spaces for persons with mobility impairments by local law or ordinance. Contact your local government if you have a question about designated parking for the mobility impaired.