DMV 41-TR (Rev.10/02)

WEST VIRGINIA DIVISION OF MOTOR VEHICLES

CHARLESTON, WV 25317

PARKING APPLICATION FOR MOBILITY IMPAIRED PERSONS

SECTION 1: APPLICANT INFORMATION Please print in ink or type all of the following information

Name Last First Middle

Social Security Number

Mailing Address/ Physical Address

Daytime Telephone Number

City State

Zip Code

Date of Birth

Sex

Indicate type of permit desired □ Placard □ Plate

Check box that applies □ Original Placard □ Renewal of Placard □ Duplicate Placard – Lost or Stolen

Current Plate Number

Lost or Stolen Plate Number

COMPLETE THE FOLLOWING ONLY IF REQUESTING A LICENSE PLATE

Title Number

Make

Year

Weight

Current License Plate

Vehicle Identification Number

I certify that I am a person with a mobility impairment which limits or impairs my ability to walk. I understand that any false statement may result in legal penalties pursuant to West Virginia Code 17C-13-6. A parent or legal guardian may sign for the applicant if the applicant is unable to do so. Please note your relationship to the applicant.

SIGNATURE OF APPLICANT OR PARENT / OR LEGAL GUARDIAN

DATE

SECTION 2. Complete only if you regularly transport the above person and wish to obtain a permit.

Section 1 must be completed and signed.

Name Last First Middle

Social Security Number

Mailing Address / Physical Address

Daytime Telephone Number

City State

Zip Code

Relationship to Applicant

Signature of Person who Transports

Date

SECTION 3. PHYSICIAN’S CERTIFICATION

This section must be completed by a MD or DO.

I certify and affirm that the above described applicant is a patient of mine and in my professional opinion his/her ability to walk is limited or impaired based on one of the following reasons as outlined in Federal Law 23 CFR 1235.2(b)1-6–WV. State Law 17C13-6

□ Permanent – Valid 1-5 years

□ Temporary Valid for 6 months

Expiration depends on the date of issuance □ Cannot walk 200 feet without stopping to rest □ Cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair or other assisted device □ Is restricted by lung disease to such an extent that the person’s forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than on liter, or the arterial oxygen tension is less than 60mm/hg on room air at rest. □ Uses portable oxygen □ Has a cardiac condition to the extent that the person’s functional limitations are classified in severity as Class III of Class IV according to standards set by the American Heart Association □ Are severely limited in their ability to walk due to arthritic, neurological, or orthopedic condition Note: Please fill out this entire section. Failure to do so will result in this form being returnedtothe sender for completion. All physician’s signatures and medical licenses are subject to review and verification. Physicians may be required to submit further documentation to substantiate the disability.

Physician’s Name ( Please print in ink or type

Medical License Number

Medical License Expiration Date

Business Address

City

State

Zip Code

Signature

Date

Telephone Number

FOR DMV USE ONLY

Issued by

Issue Date

Expiration Date

□ Lost □ Stolen

Placard / Plate Number

Previous Placard / Plate Number

INSTRUCTIONS

NOTE: All Applicants must be West Virginia residents:

1. Mobility impaired person completes Section 1 – complete and sign the entire section
2. When a person who regularly transports an applicant, applies for a placard or plate on behalf of a mobility impaired person, Section 1 must be completed and signed
3. A licensed physician completes Section 3
4. The completed application can be processed at any DMV Regional office or submitted by mail to the address listed below:

Division of Motor Vehicles

Mobility Impaired Placard & Plates

Building 3, Capitol Complex

Charleston, WV. 25317

Placard Display Information

When parked in a mobility impaired parking space, display the placard by hanging the placard on the rearview mirror or, in the absence of a mirror post, on the dashboard.

Replacement

If a parking placard or special license plate has been lost, stolen, mutilated or destroyed, a replacement may be requested at any DMV Regional offices or by mail to the DMV in Charleston. The cost of a replacement placard is $5.00 per placard. Customer must complete a new application, doctor’s recertification is not required.

Renewal

Permanent mobility impaired parking placards & plates privileges and the special ID cards are renewed every FIVE years. Renewal reminders will be mailed prior to expiration, to the address you have provided. However, the license plate expires each or every other year.

Return Placards & Plates When:

1. The person to whom the permit has been issued is deceased or has moved out of state.
2. The person has found or has in his/ her possession a permit that was not issued to that person.
3. The permit was reported lost or stolen and is later found after a duplicate has been issued.
4. Special license plates shall be surrendered to your local DMV Regional office.

Penalties

A fine of up to $500.00 may be assessed for filing fraudulent applications for a mobility impaired parking permit. This fine also applies to the misuse of a parking space reserved for persons with a walking mobility impairment.

Remember

It is unlawful to loan this placard to any person for any reason, regardless of whether that person is mobility impaired. The mobility impaired person does not have to own or drive the vehicle to use the placard. Placard should be hung from the rearview mirror when parked, but should be removed from the mirror when driving.

Local governments designate parking spaces for persons with mobility impairments by local law or ordinance. Contact your local government if you have a question about designated parking for the mobility impaired.

Mobility Impaired License Plates and Motorcycle

Information concerning transfer and fees for obtaining a plate or exchange, call TOLL FREE

1-800- 642-9066(in state) or 304-558-3900.