Form Hsmv 83039 - Application For Disabled Person Parking Permit - Florida Department Of Highway Safety And Motor Vehicles - 2013

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FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES

APPLICATION FOR DISABLED PERSON PARKING PERMIT

*******SUBMIT APPLICATION TO YOUR LOCAL COUNTY TAX COLLECTOR'S OFFICE OR LICENSE PLATE AGENCY*******

This form is not valid for more than 12 months from the date of the certifying authority’s signature.

APPLICATION BY DISABLED PERSON (See Warning Below)

Please Print/Type below

I certify that I am a person with one of the disabilities listed in section 320.0848, Florida Statutes. I further state that my physician or other

certifying practitioner has completed the statement of certification below on my behalf, as required in section 320.0848, Florida Statutes.

Name of Disabled Person as printed on their

Current Disabled Parking Permit Number

Signature of Disabled Person or Guardian of the Disabled

Florida Driver License or Florida ID Card

(if applicable)

Person

Date of Birth

Sex

Disabled Person’s E-mail Address

Disabled Person’s Phone Number Date Signed

Address

City

State

Zip

Florida Driver License or Florida ID Number:

If applicable, check one of the following:

(Required for permanent and temporary parking permits

I am a frequent traveler.

I am a quadriplegic.

unless exception is noted by physician below)

PHYSICIAN/CERTIFYING PRACTITIONER'S STATEMENT OF CERTIFICATION (See Warning Below)

TEMPORARY PERMIT: This is to certify that the applicant named above is a person with a temporary disability (six months or less) that limits or impairs his/her ability to

walk or is temporarily sight impaired. Due to the temporary specific disability(ties) checked below (2-8), the disabled person parking permit should be issued from

__________________________ (date) through ___________________________ (date).

PERMANENT PERMIT: This is to certify that the applicant named above is legally blind or is a disabled person with a permanent disability (ties) that limits or impairs

his/her ability to walk 200 feet without stopping to rest. Specify below (2-8) either legally blind or the specific disability (ties).

DISABILITY TYPE AS DISPLAYED IN FRVIS:

2. Inability to walk without the use of or assistance from a brace, cane, crutch, prosthetic device, or other assistive device, or without assistance of another person. If the

assistive device significantly restores the person's ability to walk to the extent that the person can walk without severe limitation, the person is not eligible for the

exemption parking permit.

3. The need to permanently use a wheelchair.

4. Restriction by lung disease to the extent that the person's forced (respiratory) expiratory volume for 1 second, when measured by spirometry, is less than one liter or

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

5. Use of portable oxygen.

6. Restriction by cardiac condition to the extent that the person's functional limitations are classified in severity as Class III or Class IV according to standards set by the

American Heart Association.

7. Severe limitation in a person's ability to walk due to an arthritic, neurological, or orthopedic condition.

8. Legally Blind (This is the only disability an Optometrist can certify.)

WARNING

Any person who knowingly makes a false or misleading statement in an application or certification under section 320.0848, Florida Statutes, commits a

misdemeanor of the first degree, punishable as provided in section 775.082 or 775.083, F.S. The penalty is up to one year in jail or a fine of $1,000 or both.

Certification or License No. (Required) _____________________________ of a Physician, Osteopathic or Podiatric Physician, Chiropractor,

Optometrist, Advanced Registered Nurse Practitioner under the protocol of a licensed physician or a Physician Assistant licensed under

Chapter 458 or 459.

LICENSED IN THE STATE OF

Print/Type Name of Certifying Authority

Business Address

City

State

Zip

Certifying Authority Signature

Date Signed:

(Area Code)Telephone Number

SPECIAL EXCEPTION: The severely disabled applicant named above applying for a permanent placard is unable to obtain a Florida driver license or Identification card.

If the Special Exception box is checked, the certifying physician must provide his/her signature and date signed below.

If the Special Exception box is checked, one of the conditions in boxes 2-8 above must also be checked.

Certifying Authority Signature:

Date Signed:

APPLICATION BY AN ORGANIZATION (See Warning Above)

This is to certify that

________ provides regular transportation service to disabled persons having disabilities that limit or impair

their ability to walk or are certified to be legally blind.

Number of Vehicles in fleet for this purpose:

FEID NUMBER

Organization’s E-mail Address

Signature of Organization’s Authorized Representative