Form Mva – Fill Out and Use This PDF

VRVR-210-210-6b(9(5-18)

Application for Maryland Parking Placards/ License Plates

Mail completed application to the Motor Vehicle Administration

6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062 Attn: Disability Unit

Please read instructions on back carefully before completing form.

A. Customer Identifying Information - Individual with a Disability

Attention: I/We certify the statements made herein are true and correct to the best of my/our knowledge, information and belief. I/We understand it is illegal for anyone to park in any parking space designated for a person with a disability, other than an individual who has submitted and obtained a certification from the MVA, that authorizes the use of a designated parking space. I/We also understand that the individual who has been certified to have a disability must have a current disability certification card

in his or her possession when using a disability placard or plate.

I further understand that applying for a disability placard or plate and by execution of this authorization, I give permission to my doctor to release to the Motor Vehicle Administration all medical information relative to the qualification requirements that established my eligibility to obtain the disability placard or plate. Additionally, I agree to release the MVA from any and all liability that may arise from the collection and storage of medical information, in the procurement of this application. This authorization

will not expire unless all disability placards and plates in my possession are expired or I have returned all placards and plates for cancellation.

Signature of Individual with Disability or Guardian of individual with disabilityDate

B. Requested Service: q New q Replacement q Lost placard(s) q Stolen Placard(s)

Placard number(s):_______________________________ Police Report # of Stolen Placard(s):_____________________ Jurisdiction Reported:___________________________

C. Disability Certification Information (doctor’s use only - see disability codes on back)

Please note if your patient has a temporary disability, you should only recommend a temporary placard for a period of 1-6 months. If an extension is required, your patient can apply for an additional period of disability, for up to six months. This will require the approval of the appropriate clinician. A permanent disability status should be reserved for conditions that will not improve.

TYPE OF DISABILITY:

q

PERMANENT

q

TEMPORARY

q

Disabled Veteran

Patient Name:

Disability Code:

Length of temporary disability (Temp. placard only):

q

1 mo

q

2 mo

q

3 mo

q

4 mo

q

5 mo

q

6 mo

Reason for temporary disability (Temp. placard only:)

Type of Doctor:	q	Licensed Physician	q	Licensed Chiropractor		q	Licensed Optometrist	q	Licensed Podiatrist
	q	Licensed Nurse Practitioner				q	Licensed Physician’s Assistant	q	Licensed Physical Therapist
Doctor’s or Nurse Practitioner’s Name (printed):					Signature:					Date:

Office Address:

D. Vehicle Owner Information - By signing above, I certify that I understand that my vehicle may be parked in a parking space reserved for a disabled person only when

the individual named above is present and in possession of a current Disability Certification Card.

6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062

For more information visit our website at www.mva.maryland.gov, call 410-768-7000 or TTY for the hearing impaired: 1-800-492-4575.

Instructions:

Form Purpose: An individual with a disability may use this form to request placards, license plates and/or motorcycle plates that will allow a

vehicle in which he/she is riding to park in a parking space reserved for the disabled. Two types of placards are available: Temporary Placards, which are valid for a period of up to 6 months; and Permanent Parking Placards which are valid until the death of the disabled individual. An applicant may request a parking placard, license plate and motorcycle plates at the same time. See the Form Completion Instructions below.

Fee Information:

There is not a fee for the placard(s). A request for a disability plate and/or motorcycle plate requires the assessment of the substitute/replacement tag fee. Please submit your completed application along with the appropriate $20.00 fee. If requesting a disability plate and/or motorcycle plate(s) and it’s time to renew your vehicle registration, the registration renewal fee is also required.

Form Completion Instructions:

An individual with a permanent disability may apply for:

•One placard, or

•One regular disability plate, or

•One placard and one regular disability plate, or

•Two placards

In addition, up to two motorcycle disability plates can be requested with any combination listed above.

An individual with a Temporary disability may apply for:

One or two temporary placards

Parking Placard – Complete Sections A,B and approved medical provider complete Section C. (See Note below).

License Plates or Motorcycle Plates – Complete Sections A, B, D and approved medical provider complete Section C. (See Note below). (You may only request a disability plate or motorcycle plate(s) if the vehicle is titled in the name of the individual with a disability).

Note:

•A doctor’s certification may not be required if the individual has a disability that meets the definition of code 6 or V.

•For a replacement placard, only complete Sections A and B. For replacement plates, complete Sections A, B and D.

•For temporary placards, Disability Code 10 is to be used.

Permanent Disability Codes 1-9
1. Has lung disease to such an extent that forced (respiratory)	8. Has a permanent disability, that adversely impacts the ambulatory
expiratory volume for one second, when measured by spirometry,	ability of the applicant and which is so severe that the person would
is less than one liter, or arterial oxygen tension (p02) is less than 60	endure a hardship or be subject to a risk of injury if the privileges
mm/hg on room air at rest.	accorded a person for whom a vehicle is specially registered were
	denied.

2.Has cardiovascular disease limitations classified in severity as Class

		III or Class IV according to standards set by the American Heart		9. Has a permanent impairment of both eyes so that: 1) The central
		Association.		vision acuity is 20/200 or less in the better eye, with corrective
				glasses, or 2) There is a field defect in which the peripheral field has
				contracted to such an extent that the widest diameter of visual field
3.		Is unable to walk 200 feet without stopping to rest.		subtends an angular distance no greater than 20 degrees in the better
				eye. (See Note C)
				10. Temporary Placard requested
4.		Is unable to walk 200 feet without the use of, or the assistance from,
		a brace, cane, crutch, another person, prosthetic device, or other		Disability is not permanent but would substantially impair the person’s
		assistance device.		mobility or limit or impair the person’s ability to walk for at least three
				weeks, and is so severe that the person would endure a hardship or
5.		Requires a wheelchair for mobility.		be subject to risk of injury if the Temporary Permit was denied.
6.		Has lost an arm, hand, foot, or leg. (See Note D)		V. (Reserved for use by veterans with 100% disability) The Veterans
				Administration has certified by letter that the applicant has a 100%
		Has lost the use of an arm, hand, foot or leg.
7.				service connected disability.

Notes:

A. A licensed physician, licensed nurse practitioner or licensed physician’s assistant may certify all qualifying conditions listed. B. A licensed chiropractor, licensed podiatrist or licensed physical therapist may certify disability codes 3 through 8 and 10. C. A licensed optometrist may certify only qualifying conditions regarding vision.

D.The person with a disability may self-certify the conditions listed under Disability Code 6 by appearing in person with proper identification. In this situation, only the disabled person’s name and Disability Code must be recorded. If, however, a doctor certifies the loss of a limb, the doctor must complete all of Section C.

Visit your local MVA full service office with the completed form. If someone other than the applicant submits the application for Disability Plates or Placards they must provide a state issued ID. Applications may also be mailed with the appropriate fees to the Motor Vehicle Administration, 6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062. Attn: Disability Unit

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