Form Mvr 32 6 230 – Fill Out and Use This PDF

Disability Access parking credentials may be issued to an individual with a disability or a parent, stepparent, or legal guardian of an individual with a disability. Applicants with permanent disabilities are eligible for two (2) disability placards per person OR one (1) placard per person AND one (1) license plate decal per vehicle. There is no fee for placards or decals. Organizations that transport individuals with disabilities are eligible to apply for a Disability Access license plate decal.

Mark Individual, Parent, Stepparent, or Legal Guardian of an individual with a Disability, or Organization.

Enter the APPLICANT NAME, COUNTY and TELEPHONE NUMBER.

Enter the PHYSICAL ADDRESS with CITY, STATE and ZIP, and the MAILING ADDRESS (IF DIFFERENT FROM PHYSICAL) with CITY, STATE and ZIP.

Enter the DRIVERʼS LICENSE (OR NON-DRIVER ID), ISSUING STATE, EXPIRATION DATE (MONTH/YEAR) and EMAIL ADDRESS.

Enter the FEDERAL EMPLOYER IDENTIFICATION NUMBER (ORGANIZATION ONLY).

Under CREDENTIALS BEING REQUESTED, mark DISABILITY ACCESS LICENSE PLATE DECAL (Permanent Disability only) for a decal and DISABILITY ACCESS PLACARD(S) for placards; mark only the credentials you are requesting.

Mark the APPLICATION TYPE: NEW or RENEWAL.

For REPLACEMENT, select the reason for replacement: Lost, Stolen or Mutilated.

Applicant certifies, under penalty of perjury, that the applicant meets the requirements necessary to receive disability access parking credentials; sign at APPLICANT SIGNATURE and enter the DATE.

An individual with qualified disabilities must obtain certification from a licensed physician, certified registered nurse practitioner, or certified nurse midwife prior to the initial issuance of disability access credentials. An individual with permanent disabilities may self-certify their qualifying disability if they are renewing their disability access credentials. A separate certification is not required to obtain replacement disability access credentials.

An individual with disabilities which limits or impairs their ability to walk means (check all that apply): Cannot walk two hundred feet without stopping to rest; Cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device; Are restricted by lung disease to such an extent that the personʼs forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than 60 mm.hg on room air at rest; Use portable oxygen; Have a cardiac condition to the extent that the personʼs functional limitations are classified in severity as Class III or Class IV according to standards set by the American Heart Association; Are severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition.

Check the length of disability: Permanent Disability, or Temporary Disability (period not to exceed six months), with Beginning Date and Ending Date.

The undersigned affirms under penalty of perjury that the applicant has the specific disability(ies).

Authorized Signature (Must be physician, certified registered nurse practitioner or certified nurse midwife signature) with the Date, Printed Name, Medical License Number (if applicable), Telephone Number, and Office Address, City, State and Zip.

Return this application to your local licensing office.