Dmv 41 Tr Form PDF Details

The DMV-41-TR form, a crucial document from the West Virginia Department of Transportation Division of Motor Vehicles, serves individuals with mobility impairments seeking to obtain special parking privileges. This comprehensive form, revised in March 2014 and reviewed in March 2015, offers a detailed procedure for applicants to follow, ensuring they provide all necessary information to facilitate their request. It encompasses sections for personal information, including the essential Social Security Number, and details regarding the type of request—be it for a mobility impaired license plate or placard, both of which have specifications on issuance depending on whether the request results from a loss or theft. Additionally, vehicle and insurance information is only required when the application is for a license plate, underlining the tailored approach of the form to different needs. Crucial to the process is Part II, which must be filled out by a licensed physician, certifying the mobility impairment through various criteria, thereby substantiating the applicant’s need. This form not only represents a vital step towards autonomy and ease of access for those with mobility impairments but also illustrates the thoughtful considerations of the West Virginia DMV in accommodating residents' diverse needs. Instructions included with the form stress the importance of accurate and complete application to avoid delays, pointing out the requirements for both the applicant and the certifying physician, along with the guidelines for proper use and renewal of issued placards and plates.

QuestionAnswer
Form NameDmv 41 Tr Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdmv 41 tr for individuals, wv handicap application, wv handicap parking permit, wv dmv handicap form

Form Preview Example

DMV-41-TR REVISED 3/14 (REVIEWED 3/15)

West Virginia Department of Transportation

Division of Motor Vehicles

Parking Application for a Mobility Impaired Person

Mail to: Mobility Impaired Placards & Plates • PO Box 17010 • Charleston, WV 25317

Questions: 1-800-642-9066 • www.dmv.wv.gov

Applicant MUST Enter SSN Below

DMV Completes Placard Detail Below

Plate and/or Placard Detail

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 (

)

-

 

LAST

FIRST

MIDDLE

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

CITY

 

 

STATE

 

ZIP

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?

Please list the lost or stolen plate number: ____________________

Request for a Mobility Impaired Placard

Is this request due to a LOST or STOLEN placard?

Please list the lost or stolen placard number: ____________________

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

Make

Current

License

Plate # (INCLUDE SPACES)

Weight

Vehicle

Number

MODEL YEAR

 

 

 

 

TITLE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VIN/SERIAL NUMBER

Policy No.

NAIC Number

Insurance Company

Insurance Agent

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.

 

(X)

 

/

/

 

 

 

 

 

 

 

 

 

 

 

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

 

DATE

 

 

 

 

 

 

 

 

 

 

PART II TO BE COMPLETED ONLY BY A LICENSED PHYSICIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Condition:

Permanent • Valid for 1-5 Years

Temporary • Valid for Six Months

 

 

 

 

 

 

 

 

 

Patient cannot walk 200 feet without stopping to rest.

Patient cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair or other assisted device.

Patient is restricted by lung disease to such an extent the person’s forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than 60mm/hg on room air at rest.

Patient uses portable oxygen.

IV according to standards set by The American

Heart Association.

Patient is severely limited in their ability to walk due to arthritic, neurological, or orthopedic condition.

COMPLETE ALL OF PART II. FAILURE TO DO SO WILL RESULT IN THIS FORM BEING RETURNED TO THE SENDER FOR COMPLETION. ALL PHYSICIAN’S SIGNATURES AND LICENSE’S ARE SUBJECT TO REVIEW FOR VERIFICATION. PHYSICIANS MAY BE REQUIRED TO SUBMIT FURTHER DOCUMENTATION TO SUBSTANTIATE THE DISABILITY.

Physician’s Name

(Please print in ink or type)

Business

Address

Signature (X)

Medical License

 

 

Medical License

/

/

Number

 

 

Expiration Date

City

 

 

State

 

Zip

 

 

 

 

 

 

Date

/

/

NumberTelephone (

 

)

-

 

 

 

 

 

 

 

 

 

 

Instructions for Completing the Form: DMV-41-TR

ALL APPLICANTS MUST BE WEST VIRGINIA RESIDENTS

1.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

2.The mobility impaired person completes Section 1 and signs the application.

3.A licensed physician completes Section 2. (Licensed physician includes MD., DO., Chiropractor, Advanced Nurse Practitioner, and Physician’s Assistant)

4.Applicants requesting a mobility impaired license plate must be listed on the registration of the vehicle listed in Sub-Section C.

Division of Motor Vehicles

Mobility Impaired Placards and Plates

P O Box 17010

Charleston, WV 25317

Placard Information

1.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.

2.If a parking placard or special license plate has been lost, stolen, mutilated or destroyed, a replacement may be requested at

3.Permanent mobility impaired placards and plates privileges and the special ID cards are renewed every years. Renewal reminders will be mailed prior to expiration, to the address you have provided. However, the license plate expires each year or every other year.

Situations that Warrant Returning Placards & Plates

1.The person to whom the permit has been issued is deceased or has moved out of state.

2.The person has found or has in his/her possession a permit that was not issued to that person.

3.The permit was reported lost or stolen and is later found after a duplicate has been issued.

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.

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Filling out segment 1 of west virginia handicap parking permit

2. The third part is to submit the following blanks: Current License Plate, INCLUDE SPACES, Policy No, NAIC Number, Number, Insurance Agent, VINSERIAL NUMBER, Insurance Company, I certify that I am a person with, the applicant if the is, SIGNATURE OF APPLICANT OR, PART II TO BE COMPLETED ONLY BY A, DATE, Type of Condition, and Permanent Valid for Years.

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west virginia handicap parking permit completion process detailed (portion 3)

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