Applying for a handicapped parking permit involves a detailed process that ensures those who genuinely need special parking considerations are duly accommodated. The application form itself serves as a crucial initial step, meticulously designed to gather essential information from applicants while ensuring compliance with regulatory standards. The form is divided into two main parts: the first to be completed by the applicant or their guardian, if the applicant is a minor, and the second part requiring completion by a licensed healthcare professional. Applicants are asked to provide personal details, including their name, contact information, and evidence of any previous permits alongside a declaration of their current need for a parking permit, whether it is a renewal or a new application. The healthcare professional's section is equally vital, demanding a precise medical diagnosis and an assessment of how the applicant’s condition affects their mobility. This part of the form confirms whether the disability is temporary or permanent, setting the stage for the type of permit issued. Moreover, the application outlines specific instructions for submission, renewal, and replacement procedures, emphasizing the importance of providing accurate and comprehensive information to avoid any delays or complications in receiving the parking permit. Residents of certain areas are directed to specific local offices for application submission, highlighting the localized nature of the permit issuance process. The application form thus serves not only as a tool for requesting a parking permit but as a guide through the procedural and regulatory pathways that safeguard the integrity of the system, ensuring that those in need receive the support they deserve.
| Question | Answer |
|---|---|
| Form Name | Handicapped Parking Permit Application Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | handicap parking permit suffolk county, brookhaven parking permit, brookhaven handicapped parking permit, town of brookhaven handicap parking permit application |
APPLICATION FOR DISABLED/HANDICAPPED PARKING PERMIT
P L E A S E T Y P E O R P R I N T C L E A R L Y
1.PERMIT NUMBER:
2.EXPIRATION DATE:
3.ID SHOWN
PART 1: TO BE COMPLETED BY APPLICANT OR PARENT / GUARDIAN IF MINOR
4. DATE
5.
New Applicant |
or |
Renewal
6. PRIOR PERMIT NUMBER
7. NAME |
LAST |
FIRST |
MIDDLE |
8. TELEPHONE
9. ADDRESS |
NUMBER & STREET |
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TOWN |
STATE |
ZIP |
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9. MAILING ADDRESS (IF DIFFERENT FROM ABOVE) |
NUMBER & STREET |
TOWN |
STATE |
ZIP |
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10. DATE OF BIRTH
11.
Male
Female
12. SIGNATURE OF APPLICANT
DO YOU HAVE A DRIVERS LICENSE OR |
IF YES, PLEAE SEND COPY OF SAME |
If signed by parent or guardian, please state your relationship to the person |
NON DRIVERS ID CARD _____ YES _____ NO |
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with the disability after your signature |
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PART 2: TO BE COMPLETED BY PHYSICIAN
13. NAME OF PHYSICIAN
16. ADDRESS |
NUMBER & STREET |
14. LICENSE NUMBER |
15. TELEPHONE |
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TOWN |
STATE |
ZIP |
17.NAME OF DISABLED PERSON
18.MEDICAL CERTIFICATION
This section must be completed by a Medical Doctor (MD) Doctor of Osteopathy (DO) or Doctor of Podiatric Medicine (DPM). Indicate below the condition which necessitates the above granted a disabled parking permit, if this condition is permanent or temporary and describe the limitations which cause difficulty in ambulation.
19. DIAGNOSIS – DO NOT ABREVIATE OR USE OFFICE CODES
20. LIMITATION/HARDSHIP – HOW CONDITION AFFECTS APPLICANT’S ABILITY TO AMULATE
21. PLEASE CERTIFY IF THE PATIENT’S DISABILITY IS PERMANENT OR TEMPORARY |
22. IF TEMPORARY, EXPECTED RECOVERY DATE |
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(TEMPORARY PERMITS ARE ISSUED FOR 6 MONTHS OR LESS) |
Permanent |
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Temporary |
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23. PERMANENT DISABILITY
A “severely disabled person” is any person with one or more of the PERMANENT impairment, disabilities or conditions listed below, which limit mobility:
Uses portable oxygen |
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Limited or no use of one or both legs |
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Unable to walk 200 feet without stopping |
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Legally blind |
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Neuromuscular dysfunction |
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Class III or IV cardiac condition |
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Has a physical or mental impairment or condition not listed above which constitutes an equal degree of disability |
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Restricted by lung disease to such an extent that forced expiratory volume for one second, when measured by spirometry, is less than one liter, or the arterial x oxygen tension is less than sixty mm/hg of room air at rest.
24. SIGNATURE OF PHYSICIAN – SIGNATURE STAMP NOT ACCEPTABLE |
25. DATE |
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HANDICAPPED PARKING PERMIT APPLICATION PROCEDURE
If you are a resident of the Village of Patchogue, you can obtain an application for a permanent or temporary handicapped parking permit from the Village Clerk’s Office at 14 Baker Street,
Patchogue. Persons not living in the Village of Patchogue must go to the Town of Brookhaven or to the Township in which they reside.
NEW PERMITS
Part I of the application is to be filled out and signed by the applicant. If your mail is delivered to a P.O. Box, you must also include your street address on the application. BRING YOUR NEW
YORK STATE DRIVER’S LICENSE OR
CURRENT PHYSICAL ADDRESS, YOU MUST ALSO BRING A UTILITY BILL, BANK STATEMENT, OR CREDIT CARD STATEMENT TO PROVE YOUR
PHYSICAL ADDRESS. A P.O. BOX DOES NOT PROVE RESIDENCY. Part II of the application must be completed (including diagnosis and professional license number) and signed
by your physical (MD, DO, NP or DPM). Chiropractors (DC) and Physician Assistants (PA) are not considered “physicians” under the Vehicle and traffic Law, Sec. 1203.
You may return the application in person or by mail (NO FAX COPIES OR PHOTOCOPIES) to the address listed on the bottom of the application. If someone other than the applicant brings in the application, they must provide all the documentation as listed above. Mail is processed promptly and you will receive your permit within a few days.
RENEWAL PERMITS
If renewing a permit, the expiring permit MUST BE RETURNED. Part I of the application must be completed and signed by applicant. Part I and II must be completed for temporary permit renewal. If your permit has expired for more than a month, follow instructions for new permits. If your permit was issued from another municipality, you must file an application as a new resident.
LOST OR STOLEN PERMITS
If your permit was lost or stolen, you must sign a sworn affidavit, have it notarize and pay a $2.00 fee. You must also compete and sign Part I of the permit application and submit your ID.
The affidavit mentioned above states that you would be issued ONE (1) replacement tag. If the replacement tag is lost or stolen the Village Clerk’s Office WILL NOT ISSUE YOU
ANOTHER TAG. You will have the option of going to the Department of Motor Vehicles for plates or returning to your doctor for a newly completed and signed form.
LOST OR STOLEN HANDICAPPED PARKING PERMIT AFFIDAVIT
PERMIT:
I, |
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of |
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First Name |
Middle |
Last Name |
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Address
Have had my assigned Handicapped Parking Permit either lost or stolen, I acknowledge that
I will not be issued any future replacement handicapped parking permits.
I will have the option of requesting car plates from the Department of Motor Vehicles or returning to my doctor for a new application that will be completed and signed by the doctor verifying that I am still in the need of the tag.
*Please note: If you lose the replacement Handicapped Permit after seeing the doctor for the second time, the Village Clerk will no longer issue another replacement.
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Signature
Sworn to before me this
Day of |
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, 20 |
Notary Public