Taxation & Revenue Department - Motor Vehicle Division
APPLICATION FOR CERTIFICATE
OF ELIGIBILITY FOR PARKING PLACARD
for Mobility Impaired Individuals
A. Applicant Information
Name
Address
City
Email Address
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Date of Birth |
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Social Security Number |
State |
Zip Code |
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Phone Number |
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ORIGINAL
Complete items A, C and D in full.
RENEWAL
Complete items A and E in full.
REPLACEMENT
Complete items A and E in full.
C. Physicians Information
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Licensed Physician’s Name |
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License Number |
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Business Address |
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City |
State |
Zip Code |
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Email Address |
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Phone Number |
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D. Physician Medical Statement & Certification
The applicant identified above is eligible for a mobility limitation parking placard because he or she (check all that apply):
cannot walk 100 feet without stopping to rest;
cannot walk without the use of a brace, cane or crutch or without assistance from another person, a prosthetic device, a wheelchair or other assistive device;
is restricted by lung disease to such an extent that the person's forced respiratory volume, when exhaling for one second, when measured by spirometry, is less than one liter or the arterial oxygen tension is less than sixty millimeters on room air at rest;
uses portable oxygen;
has a severe cardiac condition; or
is so severely limited in the ability to walk due to an arthritic, neurologic or orthopedic condition that the person cannot ascend or descend more than 10 stair steps.
This condition is |
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Permanent |
or |
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Temporary |
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A temporary placard should be issued for ______ months (12 months maximum).
I certify that the information provided above is true and correct to the best of my knowledge.
PLACARD |
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NUMBER(S) |
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EXPIRATION |
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DATE |
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month |
day |
year |
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DATE POSTED |
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TO SYSTEM |
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month |
day |
year |
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DENIED: Application
inaccurate incomplete
ISSUED
User ID: ______ FO code: ______
Date: ______________
E. Applicant Certification for Renewal or Replacement of Parking Placard
I certify that I am the person named as Applicant in Part A of this Certificate of Eligibility. Parking placard number ______________________________,
expiring on ___________________________ was issued to me. There has been no change in the mobility limitation condition(s) originally certified by
my physician.
If requesting a replacement placard, explain why a replacement is needed: ________________________________________________________________
___________________________________________________________________________________________________________________________________
______________________________________________________________________________ |
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Signature of Applicant |
Date |
INSTRUCTIONS FOR COMPLETING CERTIFICATE OF ELIGIBILITY FOR PARKING PLACARD
Statutory conditions for issuance of a parking placard:
Section 66-3-16 NMSA 1978 provides for issuance of no more than two parking placards to a resident of New Mexico who has a “significant mobility limitation,” which means that the person: (1) cannot walk one hundred feet without stopping to rest; (2) cannot walk without the use of a brace, a cane, a crutch, assistance from another person, a prosthetic device, a wheelchair or another assistive device; (3) is restricted by lung disease to such an extent that the person's forced respiratory volume, when exhaling for one second, when measured by spirometry, is less than one liter or the arterial oxygen tension is less than sixty millimeters on room air at rest; (4) uses portable oxygen; (5) has a severe cardiac condition; or (6) is so severely limited in his ability to walk due to an arthritic, neurologic or orthopedic condition that the person cannot ascend or descend more than ten stair steps.
A parking placard will generally expire on the expiration date of the person's New Mexico driver’s license or identification card. However, if the significant mobility limitation is temporary, a temporary placard may be issued for no more than one year.
No person shall falsely claim to have a significant mobility limitation so as to be issued a parking placard when the person does not in fact have a significant mobility limitation. Upon notice and opportunity to be heard, the division may revoke and demand return of any placard when: (1) it was issued in error or with false information; (2) the person receiving the placard is no longer eligible; or (3) the placard is being used by ineligible persons.
Instructions:
1.The completed and signed original form MVD-10383 Application for Certificate of Eligibility may be taken to any New Mexico Motor Vehicle Division (MVD) field office for processing. Photocopies will not be accepted.
2.Failure to complete any item as required will result in rejection of the Application for Certificate of Eligibility, and no placard will be issued.
3.All original applications must include certification (Parts C and D) by a licensed physician.
4.A renewal or replacement application may be self-certified (Part E), provided that the applicant can provide his or her current placard number and expiration date.
5.The applicant for renewal or replacement of an existing placard must provide the old placard (or the placard number and expiration date). Otherwise a new, fully completed form MVD-10383 Application for Certificate of Eligibility must be submitted. (Parts A, C and D in full)
6.Temporary placards issued, based on the physician’s statement, for a temporary condition, may not be renewed.
7.A placard issued for a permanent medical condition will expire on the same date as the individual’s New Mexico driver license or identification card. If the applicant for a new or replacement placard does not have a current New Mexico driver license or identification card, an identification card or driver license should be applied for and issued at the same time as the parking placard.
8.If you require an accommodation under the Americans with Disabilities Act (ADA) in order to complete this form and the application process, please contact our ADA Coordinator at P.O. Box 630, Santa Fe, NM 87504-0630.
CONDITIONS AND RESTRICTIONS ON USE OF PARKING PLACARD
The following conditions and restrictions apply to the use of a parking placard for mobility impaired individuals:
•The individual to whom a parking placard is issued is the ONLY person entitled to use it. The placard may be used in any vehicle the placard holder operates or in which he or she is transported.
•The placard is to be displayed ONLY when the vehicle is parked, NOT when it is in operation. A citation could be issued for obstruction of the driver’s view if the placard is not removed when the vehicle is in operation.
•Law enforcement officials are provided information on each placard that is issued. Identification may be requested to establish that an individual is entitled to use the placard. In most cases, the photo included with the placard should be sufficient to identify the authorized placard holder.
•When the vehicle is parked, the placard must be hung from the rearview mirror with the identification number and expiration date visible from the front of the vehicle. If there is no rearview mirror, the placard should be placed on the dashboard with the identification number and expiration date visible.
•No reminder notice will be mailed to the placard holder prior to the expiration date of a placard.
•If the placard holder’s medical condition changes and there is no longer a significant mobility limitation as defined in Section 66-3-16 NMSA 1978, the placard must be returned for cancellation to the Motor Vehicle Division, Placard Program, P.O. Box 1028, Santa Fe, NM 87504-1028. The placard of a deceased holder should be returned to the MVD at the same address.
