MICHIGAN DEPARTMENT OF STATE |
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Disability Parking Placard Application |
Office Use Only: |
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Expiration |
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Date: |
Directions:
Applicants please complete and sign Part 1. Your physician, chiropractor, optometrist, nurse practitioner, or physician’s assistant must complete Part 2 and the certification on the bottom of this page. If you also qualify for free parking, your physician, chiropractor, optometrist, nurse practitioner, or physician’s assistant
must also complete Part 3. Organizations applying for parking placards to provide transportation services for disabled persons complete Part 4. Completed applications may be presented at any Secretary of State branch office or mailed to the address on the reverse side of this form.
(Application cannot be processed without signed release of information and physician’s certification)
Part 1: Release of Information and Signature
I am applying for a disability parking placard as provided in Public Act 300 of 1949. I authorize the release of the medical information described below to the Michigan Department of State. I certify the information is true and realize by making a false statement on this application I am subject to the penalties described on the reverse side of this form.
(Please print)
Name (First, Middle, Last) |
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Date of Birth |
Michigan Drivers License or ID Card # |
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Street Address |
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County |
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Disability Plate Number (if any) |
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City, State, Zip |
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Daytime Phone Number |
Last Parking Permit Number |
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Do you have a CDL endorsement? |
If yes, do you have a medical |
waiver? |
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Are you a Michigan resident? |
YES |
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NO |
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YES |
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NO |
If yes, attach copy of waiver |
YES |
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NO |
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Signature of Disabled Person |
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Date |
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X |
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Signature of Representative (If presented by representative) |
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Representative’s Driver License Number |
X |
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Part 2: Medical Eligibility Standards and Physician’s Determination
The Michigan Vehicle Code [MCL 257.19a] states that a disabled person be determined by a licensed physician, physician’s assistant, chiropractor, nurse practitioner, or optometrist identifying one or more of the following characteristics which affect your patient’s ability to walk.
Circle all letters that apply |
Right Eye: |
Left Eye: |
Both Eyes: |
Visual field (in degrees): |
a) Blindness. Corrected acuity level: |
20/______ |
20/______ |
20/______ |
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b)An inability to walk more than 200 feet without having to stop and rest. Please provide the diagnosis for this ambulatory disability:_______________________________________________________________________________________
c)Patient must use a wheelchair, walker, crutch, brace, or other ambulatory aid to walk.
Describe:_______________________________________________________________________________________
d)Patient has a lung disease from which the forced expiratory volume for one second, when measured by spirometry, is less than one liter, or from which the arterial oxygen tension is less than 60mm/hg of room air at rest.
e)Patient has a cardiovascular condition which measures between 3 and 4 on the New York Heart Classification Scale, or which renders the patient incapable of meeting a minimum standard for cardiovascular health established by the American Heart Association and approved by the Michigan Department of Public Health.
f)Patient has an arthritic, neurological, or orthopedic condition that severely limits ability to walk.
Describe: _______________________________________________________________________________________
g)Patient has a persistent reliance upon an oxygen source other than ordinary air.
Physician’s Certification |
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A parking placard will be issued solely on the physician’s evaluation |
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Patient’s condition is: Permanent |
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Temporary |
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If temporary, estimated duration: ______months (maximum 6 months) |
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Physician’s Name |
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Medical Specialty |
Office Telephone |
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Street Address |
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City, State, Zip |
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Office Fax |
I certify the person listed above is eligible for a disability placard as provided in Public Act 300 of 1949. I also understand that making a false statement to obtain a disability parking placard is a misdemeanor and may result in fines, imprisonment, or both.