APPLICATION
FOR PARKING PERMIT
FOR PEOPLE WITH SEVERE
DISABILITIES
Part I CUSTOMER INFORMATION – (Please print and sign where
indicated)
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Last name First M.I. |
Telephone No. ( ) |
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Address
City State Zip code |
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Date of Birth / / |
___ Male ___ Female |
I am applying for:
__ License Plates __
Parking Permit __ Second Permit |
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I __ have __ do not have license plates for people with
disabilities. If “Yes” my license
plate number is: ____________ |
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___________________________________________
____________ (Applicants
Signature or Signature of Parent or Guardian) --If signed by parent
(Date) or Guardian, please indicate your relationship after your
signature. |
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Part
II MEDICAL CERTIFICATION – This section
must be completed only by a Medical Doctor (MD), Doctor
of Osteopathy (DO) or Doctor of Podiatric Medicine (DPM). Please certify whether the patient’s
disability is
permanent or temporary.
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Check
the box(es) that describe the disability: q
TEMPORARY DISABILITY: A temporary disabled person is any person
who is unable to ambulate without the aid of an assisting device, such as a
brace, cane, crutch, prosthetic device, another person, wheelchair, walker or
other assistive device. (Temporary
permits are issued for periods of six months or less.) Expected Recovery Date: ____________ . q
PERMANENT DISABILITY:
A “severely disabled” person is any person with one or more ot the
PERMANENT impairments, disabilities or conditions listed below, which limit
mobility. Please check the conditions
that apply. Uses portable
oxygen, Legally blind, Limited or no use of one or both legs, Unable to walk 200 ft without stopping. Neuromuscular
dysfunction that severely limits mobility Class III or IV cardiac condition (American Heart Assoc.
standards) Severely limited
in ability to walk due to an arthritic, neurological or orthopedic condition .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 sixty mm/hg of room air at rest Has a physical or mental impairment or
condition not listed above which constitutes an equal degree of disability,
and which imposes unusual hardship in the use of public transportation
and prevents the person from getting
around without great difficulty.
Describe the specific impairment, disability or condition and explain how it
limits mobility. ________________________________________________________________________ |
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_____________________________________________________________
_____________________ Ø
(Physician/Podiatrist Signature)
Date |
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I
certify that the information above is true and that I have read and understand
the conditions of this application and will comply with them. IMPORTANT: False statements are punishable under Section 210.45 of the
Penal Law. |
Part III. FILE INFORMATION (For Issuing Agent Use Only): Parking
Permit No. ______________
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PERMIT: First
Second
Permanent Temporary Issuance Date __________ Expiration Date: ___________
Denied Revoked Revocation Date: __________________ Reason: ______________________________________________________________________________________________
_________________________________________________________________________________ Ø _______________________________________________ _____________________ (Issuing
Agent)
(Locality) |