Application For Disability Access Parking Privileges
_______________ _______________
NOTICE: Return This Application To Your County Licensing Office
To Acquire Disability Access Placards and/or License Plates. APPLICANTS NAME
TELEPHONE NUMBER
( STREET ADDRESS PHYSICAL LOCATION
CITY
COUNTY
MAILING ADDRESS
STATE
ZIP
CITY
STATE
ZIP
Individuals with qualified disabilities must obtain a licensed physicians certification prior to the initial issuance of disability access placards and/or license plates. Individuals with long-term disabilities may self-certify their qualifying disability if they are renewing their disability access placards and/or license plates for the five year period beginning in 2012.
Indicate below which privilege is being requested:
DISABILITY ACCESS LICENSE PLATE(S) (to include disability access military and motorcycle plates) issued only for vehicles owned by (a) persons with a disability as described below; and (b) organizations that transport persons with a disability as described below. DISABILITY ACCESS PLACARD(S) issued only to persons with a disability, as described below, who have a LONG-TERM limitation or impairment in their ability to walk. TEMPORARY DISABILITY ACCESS PLACARD(S) issued only to persons with a disability, as described below, who have a TEMPORARY limitation or impairment in their ability to walk (not to exceed six months).
I certify, under penalty of perjury, that I meet the
requirements necessary to receive a disability access license plate/placard as listed in the section below:
APPLICANTS SIGNATURE (OR LEGAL GUARDIAN)
DATE
REQUIREMENTS AND PHYSICIANS CERTIFICATION
Disability Access license plates and placards may be issued to: (a) persons with a disability which limits or impairs their ability to walk; or (b) organizations that transport persons with a disability which limits or impairs their ability to walk (except that organizations shall not be eligible for placards). As determined by a licensed physician, persons with disabilities which limit or impair their ability to walk means persons who:
(1) Cannot walk two hundred feet without stopping to rest; or
(2) Cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device; or (3) Are restricted by lung disease to such an extent that the persons 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 mm.hg on room air at rest; or (4) Use portable oxygen; or (5) Have a cardiac condition to the extent that the persons functional limitations are classified in severity as Class III or Class IV according to standards set by the American Heart Association; or (6) Are severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition.
Physician, check the number(s) above representing the applicants specific disability which limits or impairs his/her ability to walk and indicate below the length of disability if temporary.
Long-term Disability. Temporary Disability (period not to exceed six months). Beginning Date: ______________________ Ending Date: _______________________
The undersigned affirms under penalty of perjury that the applicant listed above has the specific disability(ies) as checked above.
LICENSED PHYSICIANS SIGNATURE
TYPE OR PRINT NAME
TELEPHONE NUMBER
CITY
STATE
DISABILITY ACCESS APPLICANTS SELF-CERTIFICATION
I certify, under penalty of perjury, that I continue to meet the requirements for the disability access license plate/placard as issued for the previous period.
APPLICANTS SIGNATURE (OR LEGAL GUARDIAN)
See Reverse Side For Organizational Certification, Fees, Quantities, and Other Important Information
DATE
ORGANIZATIONS ONLY
For Organizational Use. If you are an organization that transports persons with disabilities as described above, check here and DO NOT complete the Physicians Certification section.
I certify that the vehicle being registered is primarily used to transport persons with disabilities as described above:
ORGANIZATION NAME AND ADDRESS
AUTHORIZED OFFICIALS SIGNATURE
TELEPHONE NUMBER
FEES, QUANTITIES AND OTHER IMPORTANT INFORMATION
1. Return this application to your county licensing office to acquire disability access license plates and/or disability access placards. 2. Fees for disability access parking privileges: $23.00 regular license plate fee for each private passenger automobile; $15.00 regular license plate fee for each motorcycle plate; no charge for disability access placards. Fees (or exemption from fees) for disability access military license plates, such as a disabled veteran disability access plate, shall be the same as the distinctive military license plate. 3. Qualified applicants are entitled to one disability access plate for each motor vehicle they own. They may also obtain one disability access placard regardless of the vehicles owned by the applicant. Qualified applicants not obtaining a disability access license plate are eligible for one additional placard (for a maximum of two). 4. Applicants who are temporarily qualified may receive one temporary disability access placard. 5. Placards must be displayed in a manner which allows them to be viewed from the front and rear of the vehicle, hung from the front windshield rearview mirror, and utilized in a parking space reserved for persons with disabilities. When there is no rearview mirror, the placard shall be displayed on the dashboard. Remove the placard from sight when not parked. 6. Disability access license plates, placards, and temporary disability access placards are the only recognized means of identifying vehicles permitted to utilize disability access parking spaces. 7. Federal law requires that all states recognize disability access license plates, placards, and temporary disability access placards from all other states and countries. 8. A separate physicians certification is not required to obtain additional disability access license plates, placards, or temporary disability access placards. COMPLETE THE SECTION BELOW FOR REPLACEMENT OF LOST, STOLEN, OR MUTILATED DISABILITY ACCESS PLATES OR PLACARDS
ALABAMA DEPARTMENT OF REVENUE
FORMER LICENSE PLATE NUMBER
FORMER PLACARD NUMBER
MOTOR VEHICLE DIVISION
Application For Replacement
Disability Access License Plate and/or Placard
REPLACEMENT LICENSE PLATE
NUMBER
REPLACEMENT PLACARD NUMBER
NOTICE: Return This Application To Your County Licensing Office
To Acquire Disability Access Placards and/or License Plates. APPLICANTS NAME
TELEPHONE NUMBER
( STREET ADDRESS PHYSICAL LOCATION
CITY
COUNTY
MAILING ADDRESS
STATE
ZIP
CITY
STATE
ZIP
PRIVILEGE TO BE REPLACED AFFIDAVIT
Indicate below which privilege is being replaced:
DISABILITY ACCESS LICENSE PLATE(S) (to include disability access motorcycle plates). DISABILITY ACCESS PLACARD(S) for persons who have a LONG-TERM limitation or impairment in their ability to walk. TEMPORARY DISABILITY ACCESS PLACARD(S) for persons who have a TEMPORARY limitation or impairment in their ability to walk (not to exceed six months).
I certify, under penalty of perjury, that the disability access privilege indicated above is being replaced for the reason checked below:
