DMV-14-TR-WEB West Virginia Division of Motor Vehicles
Application for Parking for Person with a Disability

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SECTION 1: APPLICANT INFORMATION

Please print in ink or type all of the following information:

Name        Last First Middle

Social Security Number

Mailing Address City State Zip Code
Date of Birth Sex

Indicate type of permit desired:             Plate              Placard
Lost/stolen plate number Lost/stolen placard number

If requesting a plate or placard duplicate, please indicate if the original was:           Lost      Stolen

The line of information below is only required 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 disability which limits or impairs my ability to walk.  I understand that any false statement may result in legal penalties pursuant to West Virginia Motor Vehicle Law §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/Legal Guardian Date
   
SECTION 2: PHYSICIAN'S CERTIFICATION
I certify 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 23 CFR 1235.2(b) 1-6:

  Permanent (2 year exp.)     Temporary (1 to 3 months)        Temporary (4 to 6 months)
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 assistive 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 one 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 an arthritic, neurological or orthopedic condition

Note: Please fill out this entire section.  Failure to do so will result in this form being returned to the sender for completion.  All physicians' 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

If you have any questions concerning fees or requirements, please read our instruction page.