Form Dmv-41-Tr - Parking Application Form For A Mobility Impaired Person

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DMV-41-TR

REVISED 3/14 (REVIEWED 3/15)

Applicant MUST Enter SSN Below

West Virginia Department of Transportation

Division of Motor Vehicles

DMV Completes Placard Detail Below

Parking Application for a Mobility Impaired Person

Plate

and/or

Mail to: Mobility Impaired Placards & Plates • PO Box 17010 • Charleston, WV 25317

Placard

Questions: 1-800-642-9066 •

Detail

PART I •

TO BE COMPLETED BY THE APPLICANT

(You must follow the Instructions provided on the back of this form.)

A.) Applicant Information •

DO NOT FORGET TO ENTER YOUR SOCIAL SECURITY NUMBER IN THE LIGHT GRAY BOX ABOVE.

Name

Phone (

)

Gender

Birthdate

LAST

FIRST

MIDDLE

Address

STREET ADDRESS

CITY

STATE

ZIP

B.) Plate and/or Placard Information •

License plates can only be issued to an applicant whose name appears on the WV vehicle registration.

Request for a Mobility Impaired Plate

Request for a Mobility Impaired Placard

Is this request due to a

LOST or

STOLEN plate?

Is this request due to a

LOST or

STOLEN placard?

Please list the lost or stolen plate number: ____________________

Please list the lost or stolen placard number: ____________________

C.) Vehicle and Insurance Information •

This section is only required to be completed if this request is for a license plate.

Make

Weight

MODEL YEAR

TITLE NUMBER

Current

Vehicle

License

Plate #

Number

(INCLUDE SPACES)

VIN/SERIAL NUMBER

Policy No.

Insurance Company

NAIC Number

Insurance Agent

I certify that I am a person with a mobility impairment which limits or impairs my ability to walk and that all of the information above is accurate. I understand

that any false statement may result in legal penalties pursuant to West Virginia Code §17C-13-6. A parent or legal guardian may sign for the applicant if the is

unable to do so. Please note your relationship to the applicant.

(X)

SIGNATURE OF APPLICANT OR SIGNATURE OF LEGAL GUARDIAN AND RELATIONSHIP TO THE APPLICANT

DATE

PART II •

TO BE COMPLETED ONLY BY A LICENSED PHYSICIAN

Type of Condition:

Permanent • Valid for 1-5 Years

Temporary • Valid for Six Months

Patient cannot walk 200 feet without stopping to rest.

Patient cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair or other assisted device.

Patient is restricted by lung disease to such an extent the person’s forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one liter, or

the arterial oxygen tension is less than 60mm/hg on room air at rest.

Patient uses portable oxygen.

IV according to standards set by The American

Heart Association.

Patient is severely limited in their ability to walk due to arthritic, neurological, or orthopedic condition.

COMPLETE ALL OF PART II. FAILURE TO DO SO WILL RESULT IN THIS FORM BEING RETURNED TO THE SENDER FOR COMPLETION. ALL PHYSICIAN’S SIGNATURES AND

LICENSE’S ARE SUBJECT TO REVIEW FOR VERIFICATION. PHYSICIANS MAY BE REQUIRED TO SUBMIT FURTHER DOCUMENTATION TO SUBSTANTIATE THE DISABILITY.

Physician’s Name

Medical License

(Please print in ink or type)

Number

Expiration Date