Sp41 Form Details

Have you ever had to fill out the Sp41 form? If you are a federal employee, then you may have had to do this multiple times. The Sp41 form is an important document that is used to request information from an individual's personnel file. Generally, this form is used to request information about job performance or specific incidents that may have occurred while the individual was employed with the government. In order to ensure that the requested information is accurate and complete, it is important to understand how to properly fill out the Sp41 form. This blog post will provide a comprehensive overview of the Sp41 form and explain how to fill it out correctly.

This knowledge will help you understand better the details of the sp41 form before you begin filling it out.

QuestionAnswer
Form NameSp41 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessp 41 form, sp 41, handicap parking application, sp41 form

Form Preview Example

Application for Vehicle License Plates

and/or Placard for Persons

with a Disability

Management Operation Services Special Plate Unit

225 East State Street P.O. Box 015 Trenton, NJ 08666

609-292-6500 ext. 5061

This is my: Initial Application

Recertification Application

Replacement Application

I am applying for: License Plates Placard

Both

SECTION A: PERSONS WITH A DISABILITY IDENTIFICATION CARD INFORMATION

Name of Person with a Disability

Street Address

City, State, Zip Code

Driver License Number

Expiration Date

Date of Birth

Sex

Eye Color

Height

Weight

Daytime Telephone Number

I acknowledge that I hold a Commercial Driver License (CDL) and that this application may result in a medical review that could result in a decision that may affect my New Jersey CDL privilege.

Current Plate Number: _____________________________________________________________________________________________

Current Placard Number (for recertification applications): __________________________________________________________________

SECTION B: WHEELCHAIR SYMBOL LICENSE PLATES (Photocopy of Registration Required)

Registered Vehicle Owner’s Name

Vehicle Plate Number

Expiration Date

Registered Vehicle Owner’s Driver License Number

Expiration Date

Street Address

City, State, Zip Code

Relationship to the Disabled Applicant: Self Spouse Parent Guardian Other (Please Specify): _______________

SECTION C: REPLACEMENT PLATES, PLACARD AND/OR IDENTIFICATION CARD

License Plates

Placard

Identification Card

Vehicle Plate Number

Placard Number

Expiration Date

Expiration Date

Check One: Lost – attach a notarized statement of loss.

Damaged – return plate(s), placard, and/or both

Stolen – plate(s), placard – attach police report

SECTION D: CERTIFICATION OF STATEMENTS

I certify, under penalty of law, that the statements on this application are true.

Signature of Registered Vehicle Owner: ______________________________________________________ Date: _____________________

Signature of Person with a Disability: ________________________________________________________ Date: _____________________

Visit us at www.NJMVC.gov

New Jersey is an Equal Opportunity Employer

SP-41 (R11/20)

Application for Vehicle License Plates

and/or Placard for Persons

with a Disability

SECTION E: MEDICAL PRACTITIONER OR DISABLED VETERAN CERTIFICATION

Name of Medical Practitioner or Representative of the U.S.D.V.A.

Street Address

City, State, Zip Code

Daytime Telephone Number

Required prescription attached Required letterhead attached (ONLY for medical practitioners who are not authorized to write prescriptions OR a representative of the U.S.D.V.A.)

By law, eligibility for license plates and/or a placard for persons with a disability is limited to the following conditions. (NO OTHER PERSON IS ELIGIBLE FOR LICENSE PLATES AND/OR A PLACARD).

Patient Name (please print): _________________________________________________________________________________________

1.Has lost the use of one or more limbs as a consequence of paralysis, amputation, or other permanent disability.

2.Is severely and permanently disabled and cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair or other assistive device.

3.Suffers from lung disease to such an extent that the applicant’s forced (respiratory) expiratory volume for one second, when measured by a spirometry, is less than one liter, or the arterial oxygen tension is less than sixty mm/hg on room air at rest; or uses portable oxygen.

4.Has a cardiac condition to the extent that the applicant’s functional limitations are classified in severity as Class III or Class IV according to standards set by the American Heart Association.

5.Is severely and permanently limited in the ability to walk because of an arthritic, neurological, or orthopedic condition; or cannot walk two hundred feet without stopping to rest.

6.Has a permanent sight impairment of both eyes as certified by the NJ Commission for the Blind (Placard only).

I CERTIFY, UNDER PENALTY OF LAW, THAT MY PATIENT (print name) ___________________________________________________

HAS BEEN PERSONALLY EXAMINED BY ME AND MEETS THE ELIGIBILITY CRITERIA AS SPECIFIED IN ITEM NUMBER(S) (select from above) ________________ AND THUS MEETS THE REQUIREMENTS FOR THE RECEIPT OF LICENSE PLATES AND/OR A

PLACARD FOR PERSONS WITH A DISABILITY.

Signature of Medical Practitioner or Representative of the U.S.D.V.A.: ________________________________________________________

SECTION F: TERMS AND CONDITIONS

1.Pursuant of N.J.S.A. 2C: 21-4(a), N.J.S.A. 2C: 43-3, and N.J.S.A. 2C: 43-6, making a false statement or providing misinformation on an application to obtain or facilitate the receipt of license plates or placards for persons with disabilities is a fourth-degree crime and a person who has been convicted of this offense may be subject to pay a fine not to exceed $10,000 and a term of imprisonment of up to 18 months.

2.Wheelchair symbol license plates may be issued for one vehicle owned, operated or leased by a person with a disability or family member providing transportation for that person.

3.Wheelchair symbol license plates must be renewed every year, disability recertification is required every three years.

4.The placard must be displayed on the rearview mirror of the vehicle whenever such vehicle is parked in a designated wheelchair symbol parking space and must be removed when the vehicle is in motion.

5.Persons with a Disability Identification Card and placards must be recertified every three years.

6.The Motor Vehicle Commission requires that a person’s disability be recertified by a qualified medical practitioner and their qualification for license plates/placard as provided under N.J.A.C. 13:20-9.1(a) 4.

7.The persons with a Disability placard and/or license plates are to be used exclusively for a person with a disability named on the identification card. The identification card is nontransferable and shall be revoked is used by any other person. If the license plate and/or placard are no longer used by the person named on the identification card, they must be returned to the New Jersey Motor Vehicle Commission. Abuse of this privilege is cause for revocation of both the license plates and/or the placard.

8.Application for a Persons with a Disability Identification Card shall be submitted to the Motor Vehicle Commission not more than 60 days following the date upon which a medical professional or representative of the United States Department of Veterans Affairs certifies that the applicant meets the definition of “persons with a disability.”

I CERTIFY, UNDER THE PENALTY OF LAW, THAT I AGREE WITH THE TERMS AND CONDITIONS OF THIS APPLICATION.

Signature of Registered Vehicle Owner: ______________________________________________ Date: _____________________________

Signature of Person with a Disability: ________________________________________________ Date: _____________________________

Visit us at www.NJMVC.gov

New Jersey is an Equal Opportunity Employer

SP-41 (R11/20)