Form Dps 302Dc 002 – Fill Out and Use This PDF

Department of Public Safety

Physical Disability Parking Placard Application

The Department of Public Safety requires approximately 20 business days after receipt to process the application.

Sections 1 and 2 of this form must be completed by applicant (patient) and physician before a disability placard can be issued. If you are only seeking a replacement placard which has been lost, stolen or destroyed, only Section 1 must be completed.

Type of placard requested:	New	Renewal	Replacement (Lost/Stolen/Destroyed)
Number of placards requested: 1 placard		2 placards (Limit 1 replacement placard if lost, stolen or destroyed during the term of the original placard)

I hereby make application to the Department of Public Safety for a physical disability parking placard. I understand I must display the official placard on the rearview mirror upon parking. I understand the placard may only be displayed in motor vehicles either operated by

me, or in which I am a passenger. I understand that any person who knowingly makes false application for a disability parking placard, or makes or allows unauthorized use thereof, is guilty of a misdemeanor and upon conviction shall be punished by a fine of $500.

______________________________________________________________________________________

Section 1 (Please print or type)

Applicant (patient) name: _____________________________________________________________ Date of birth: ___________________

(First)

(Middle)

(Last)

Mailing address: ___________________________________________________________________________________________________

(Street or P.O. box)(City)(State)(Zip)

Driver License or State Identification Card Number: _________________________________________ Phone: ________________________

(Home)

NOTICE: I understand that by signing and submitting this form, my ability to operate a motor vehicle may be reviewed by the Department as provided in 47 O.S. § 6-119, pursuant to the standards prescribed by the Driver License Medical Advisory Committee as created in 47 O.S. § 6-118.

Signature of Applicant or Person Responsible for Applicant (required): ____________________________________

NOTICE: The Department shall only consider new or renewal applications submitted

within sixty (60) days of the date of the physicians signature in Section 2.

______________________________________________________________________________________

Section 2

The following section must be completed in full by a physician licensed to practice medicine or surgery, osteopathic medicine, chiropractic, podiatric medicine, or optometry; a licensed physician assistant; or a licensed and certified advanced registered nurse practitioner.

Physician’s statement concerning the above-named applicant (patient):

In your professional opinion would this condition affect this person’s ability to safely operate a motor vehicle under normal or adverse driving conditions?  No Yes

Type of placard approved by signing physician (choose one):

I certify that the applicant’s (patient’s) physical disability described above is accurate, and said diagnosis is within the authorized scope of my practice.

Date: ______________ Physician’s name: _____________________________________ Physician’s license no. _____________________

Please print or type

Address: __________________________________________________________________________________________________________

(Street or P.O. Box)(City)(State)

Phone: ___________________________ Physician’s signature: ______________________________________________________________

Physicians must indicate the type of placard and provide all information along with their signature.

______________________________________________________________________________________

FOR DPS OFFICE ONLY

Expiration date:______________________________ Date issued:________________________ Placard number: __________________________________

______________________________________________________________________________________