Disabled Parking Placards Or License Plates Application {MED 10}

MED 10 (02/10/2018) DISABLED PARKING PLACARD OR LICENSE PLATES APPLICATION HP PLATES PERMANENT PLACARD (5 years) RENEWAL (No medical professional certification required.) ORIGINAL (Medical professional certification required.) REISSUE Lost Stolen Destroyed/Mutilated ORIGINAL PLATES submit completed form VSA 10DUPLICATE PLATES Destroyed LostREISSUE PLATES Plates never received Unreadable (letters/numbers unclear) I understand that misuse, counterfeiting, or alteration of disabled placards may result in fines up to $1000.00 and up to 6 months in jail and/or revocation of disabled parking privileges. I certify that I have a (check one): disability that limits or impairs my ability to walk or creates a safety concern while walking. I also understand that the disabled parking placard or plates issued to me cannot be loaned to anyone, including family members or friends, to benefit a person other than myself. I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation. APPLICANT CERTIFICATION (person with disability) Permanent Temporary APPLICANT SIGNATURE DATE (mm/dd/yyyy) DISABLED PARKING LICENSE PLATES (HP) (check one) I am the vehicle owner and the parent/legal guardian of a disabled dependent(s). List the name of each disabled person below. The vehicle on which HP plates will be used is specifically equipped and used for transporting groups of physically disabled persons. DISABLED LICENSE PLATEAPPLICATION FOR REPLACEMENT: (check applicable) DISABLED PARKING PLACARD DISABLED PLACARD ID CARD ONLY Lost Stolen Destroyed/Mutilated Never ReceivedREASON FOR REPLACEMENT - original was:$5.00 fee (includes ID Card)$2.00 fee$10.00 fee EMPLOYEE STAMP 15-DAY PLACARD RECEIPT NUMBER PLACARD EXPIRATION DATE (mm/dd/yyyy) TEMPORARY PLACARD (up to 6 months) DMV USE ONLY ORIGINAL REISSUE Placard Destroyed/Mutilated Stolen LostReplacement Placard ID License Plate License Plate Placard ID PlacardReplacement GENDER MALE FEMALE APPLICANT INFORMATION (person with disability) FULL LEGAL NAME (last) (first) (middle) (suffix) DMV ASSIGNED NUMBER OR SOCIAL SECURITY NUMBER CURRENT RESIDENCE ADDRESS (SEE NOTE ABOVE) CITY STATE ZIP CODE CITY OR COUNTY OF RESIDENCE DAYTIME TELEPHONE NUMBER OR CELL PHONE NUMBER MAILING ADDRESS (if different from above) (SEE NOTE ABOVE) CITY STATE ZIP CODE BIRTH DATE (mm/dd/yyyy) HAIR COLOR EYE COLOR HEIGHTFTIN WEIGHTLBS NOTE: If you enter a residence or mailing address that is other than what is currently on DMV's system, complete an "Address Change Request" (ISD 01). APPLICATION TYPE DISABLED PARKING LICENSE PLATE DISABLED PARKING PLACARDORIGINAL APPLICATION: (check applicable)* Only permanently disabled persons or institutions that transport individuals with disabilities may obtain disabled license plates. (complete form VSA 10)*$5.00 fee (includes ID Card) Purpose: Persons with disabilities use this form to apply for a disabled parking placard or disabled parking license plates. Instructions: For a parking placard OR replacement placard ID card, submit this form with applicable fees. Placard or replacement ID card will be mailed to you within approximately 15 days. Only one placard may be issued to a customer. For disabled parking license plates, submit this form, a completed License Plate Application (VSA 10) and applicable fees.For placard and/or license plates, submit forms and fees to any Customer Service Center, DMV Select or mail to DMV, Data Integrity, P.O. Box 85815, Richmond, VA 23285-5815. American LegalNet, Inc. www.FormsWorkFlow.com MED 10 (02/10/2018) Reason this patient's ability to walk is limited or impaired or creates a safety condition while walking. (check below)Is restricted by lung disease to such an extent that 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 millimeters of mercury on room air at rest. Is legally blind or deaf. Cannot walk without the use of or assistance from any of the following: another person, brace, cane, crutch, prosthetic device, wheelchair, or other assistive device.Is severely limited in ability to walk due to an arthritic, neurological, or orthopedic condition. Uses portable oxygen. Has a cardiac condition to the extent that functional limitations are classified in severity as Class III or Class IV according to standards set by the American Heart Association. Has been diagnosed with a mental or developmental amentia or delay that impairs judgment including, but not limited to, an autism spectrum disorder. Has been diagnosed with Alzheimer's disease or another form of dementia. Other condition that limits or impairs the ability to walk, or creates a safety concern while walking because of impaired judgement or other physical, developmental, or mental limitation (Specific condition description must be specified below). Cannot walk 200 feet without stopping to rest. Temporarily limited or impaired beginning date (mm/dd/yyyy) and ending date (mm/dd/yyyy)(not to exceed 6 months). Permanently limited or impaired. A permanent disability as it relates to disabled parking privileges shall mean: a condition that limits or impairs movement from one place to another or the ability to walk as defined in Virginia Code 24746.2-1240, and that has reached the maximum level of improvement and is not expected to change even with additional treatment. NOTE: (This page does not have to be completed to renew permanent placards.) LICENSED CHIROPRACTOR OR PODIATRIST MEDICAL CERTIFICATION Reason this patient's ability to walk is limited or impaired. (check below)Cannot walk without the use of or assistance from any of the following: another person, brace, cane, crutch, prosthetic device, wheelchair, or other assistive device. Is severely limited in ability to walk due to an arthritic, neurological or orthopedic condition. Cannot walk 200 feet without stopping to rest. I certify and affirm that the described applicant is my patient, whose ability to walk, based on my examination, is limited or impaired or creates a safety concern while walking as described above. I further certify and affirm that to the best of my knowledge and belief, all information I have presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation. LICENSED PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER MEDICAL CERTIFICATION LICENSED MEDICAL PROFESSIONAL CERTIFICATIONPhysicianPhysician AssistantNurse PractitionerChiropractorPodiatrist DISABILITY TYPE APPLICANT FULL LEGAL NAME (last, first, middle, suffix) MEDICAL PROFESSIONAL NAME (print) OFFICE TELEPHONE NUMBER OFFICE FAX NUMBER LICENSE TYPE LICENSE NUMBER STATE ISSUING LICENSE (required) LICENSE EXPIRATION DATE (required) MEDICAL PROFESSIONAL SIGNATURE DATE (mm/dd/yyyy)page 2 The front of this form must be completed before the medical professional signs the certification.Other condition that limits or impairs the ability to walk (Specific condition description must be specified below). American LegalNet, Inc. www.FormsWorkFlow.com