Application For Disabled Placard/plate - Massachusetts Registry Of Motor Vehicles
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4MASSACHUSETTS REGISTRY OF MOTOR VEHICLES
Medical Affairs Branch
PO Box 199100
Boston, MA 02119-9100
Telephone: (617) 351-9222
For Hand Deliveries: 630 Washington St., Boston
APPLICATION FOR DISABLED PLACARD/PLATE
THIS SIDE OF THE APPLICATION MUST BE COMPLETED IN THE DISABLED PERSON'S NAME
Disabled person must be a Massachusetts resident. Please note the information required in this
application may affect your license status.
I hereby authorize the healthcare provider completing this form to discuss and release any or all medical records
pertaining to its content with or to representatives of the Registry of Motor Vehicles.
Signature of Disabled Person
Date
Please Print Disabled Person's Information
Last Name
First Name
MI
Address
City/Town
Zip Code
(
)
Date of Birth
Social Security Number
Telephone Number
License Number
Class
Expiration Date
Restrictions
Is this the first time you have submitted an application for disabled placard/plate?
Yes
No
If applicable, please print your current disabled plate or placard number
I am applying for the following:
Placard
No fee required for a placard. (Image must be captured before a placard can be issued.)
Plate
Only issued to individuals who have a vehicle registered in their name.
DV Plate
Only issued to individuals who have a vehicle registered in their name. You must submit
a letter from the Veteran's Administration which states that your disability is at least 80
percent service connected.
Important Customer Information
Incomplete applications will not be processed. This application must be submitted within 30 days of the
healthcare provider's certification. You should allow for internal RMV processing time. Please note additional
documentation may be required.
FOR REGISTRY OF MOTOR VEHICLE USE ONLY
Approved
Date:_______________By:_______________
Not Approved
Date:_______________By:_______________
Reason Code:________
Comments:__________________________________________________________________________________
____________________________________________________________________________________________
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